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QUIZ^COMPENDS 


Obstetrics 


DR.  LANDIS. 


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Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

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A  COMPEND 

OF 

OBSTETRICS 


LANDIS 


From  The  Southern  Chnic. 

"We  know  of  no  series  of  books  issued  by  any  house  that  so  fully  meets  our 
approval  as  these  ?  Quiz-Compends  ?  They  are  well  arranged,  full,  and  concise, 
and  are  really  the  best  line  of  text-books  that  could  be  found  for  either  student 
or  practitioner. 

BLAKISTON'S    7QUIZC0MPENDS? 

The  Best  Series  of  Manuals  for  the  Use  of  Students. 

Price  of  each,  Cloth,  $1.00  net.    Interleaved,  for  taking  notes,  $1.25  net. 

4^These  Compends  are  based  on  the  most  popular  text-books  and  the  lectures  of 
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represent  the  present  state  of  the  subjects  upon  which  they  treat. 

'i^'The  authors  have  had  large  experience  as  Quiz-Masters  and  attaches  of 
colleges,  and  are  well  acquainted  with  the  wants  of  students. 

#S"They  are  arranged  in  the  most  approved  form,  thorough  and  concise, 
containing  over  900  fine  illustrations,  inserted  wherever  they  could  be  used  to 
advantage. 

4®="Can  be  used  by  students  of  any  college. 

J^f"They  contain  information  nowhere  else  collected  in  such  a  condensed,  practical 
shape. 

Illustrated  Circular  Free. 

POTTER'S  ANATOMY.  Seventh  Revised  and  Enlarged  Edition.  Including 
Visceral  Anatomy.  Can  be  used  with  either  Morris'  or  Gray's  Anatomy.  138 
Illustrations  and  16  Plates  of  Nerves  and  Arteries,  with  Explanatory  Tables,  etc. 

BRUBAKER.  PHYSIOLOGY.  Thirteenth  Edition,  with  26  Illustrations.  Enlarged 
and  Revised. 

LANDIS.  OBSTETRICS.  Ninth  Edition.  Revised  and  Edited  by  Wm.  H. 
Wells,  m.  d..  Assistant  Professor  of  ObstetricSj  Jefferson  Medical  College,  Phila- 
delphia.    80    Illustrations. 

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ING.    Seventh  Revised  Edition. 

WELLS.     GYNECOLOGY.     Fourth  Edition.     With  153  Illustrations. 

GOULD  and  PYLE.  DISEASES  OF  THE  EYE  AND  REFRACTION.  Including 
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and  109  Illustrations,  several  of  which  are  in  colors.     Fourth  Edition. 

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and  Improved.     With  104  Formuke  and  195  Illustrations. 

LEFFMANN.  CHEMISTRY,  Inorganic  and  Organic.  Fifth  Edition.  Including 
Urinalysis,  Animal  Chemistry,  Chemistry  of  Milk,  Blood,  Tissues,  the  Secretions, 
etc. 

STEWART.  PHARMACY.  Eighth  Edition.  Based  upon  Prof.  Remington's 
Text-book  of  Pharmacy. 

WARREN.  DENTAL  PATHOLOGY  AND  DENTAL  MEDICINE.  Fourth  Edition, 
Illustrated.  Containing  all  the  most  noteworthy  points  of  interest  to  the  Dental 
Student,  and  a  Section  on  Emergencies. 

HATFIELD.  DISEASES  OF  CHILDREN.  Colored  Plate.  Third  Edition,  Revised 
and  Enlarged. 

ST.  CLAIR.     MEDICAL  LATIN.     Second  Edition. 

SCHAMBERG.  DISEASES  OF  THE  SKIN.  Fifth  Edition.  Revised  and  Enlarged. 
112  Illustrations. 

RADASCH.     HISTOLOGY.     Third  Edition.     With  in  Illustrations. 

PITFIELD.    BACTERIOLOGY.    Second  Edition.    90  Illustrations. 

HIRSCH.  GENITO -URINARY  AND  VENEREAL  DISEASES,  AND  SYPHILIS. 
Second  Edition.     With  76  Illustrations. 


BLAKISTON'S      ?     QUIZ-COIVlPENDS     ? 


A  COMPEND 


OF 


OBSTETRICS 


ESPECIALLY  ADAPTED  TO  THE  USE  OF 
MEDICAL    STUDENTS    AND    PHYSICIANS 


HENRY  G.  LANDIS,  A.M.,  M.D. 

LATE   PROFESSOR   OF   OBSTETRICS  AND   DISEASES   OF  WOMEN   IN  STARLING 
MEDICAL   COLLEGE 


REVISED   AND   EDITED  BY 

WILLIAM  H.  WELLS,  M.D. 

ASSISTANT  PROFESSOR  OF   OBSTETRICS  IN  THE  JEFFERSON  MEDICAL  COLLEGE, 
PHILADELPHIA;     ASSISTANT     OBSTETRICIAN     IN     THE     MATERNITY    DE- 
PARTMENT   OF    THE    JEFFERSON   MEDICAL    COLLEGE    HOSPITAL; 
FORMERLY    ADJUNCT    PROFESSOR    OF    OBSTETRICS    AND 
DISEASES    OF    INFANCY   IN    THE    PHILADELPHIA 
POLYCLINIC;   FELLOW  OF  THE   COLLEGE 
OF  physicians;  member  of  THE 
OBSTETRICAL  SOCIETY,  ETC. 


NINTH  EDITION— ILLUSTRATED 

PHILADELPHIA 
P.  BLAKISTON'S   SON   &   CO. 

1012   WALNUT   STREET 


t 


^ 


FEB     8  1947 


Copyright,  1915,  by  P.  Blaziston's  Son  &  Co. 


THE.  MAPLE  •  PRESS.  YORK.  PA 


FEMALE  PELVIS 


MALE  PELVIS 


PREFACE  TO  THE  NINTH  EDITION. 


In  this  ninth  edition  of  Landis  Compend  the  editor  has  made  a 
number  of  changes,  both  in  the  arrangement  of  the  book  and  in 
the  addition  of  considerable  new  material.  Additions  have  been 
made  in  the  more  detailed  anatomy  of  the  female  genital  organs 
and  in  the  diagnosis  of  pregnancy.  The  operation  of  vaginal  Caesa- 
rean  section  has  been  described,  as  well  as  several  of  the  minor 
operative  procedures  in  pregnant  and  parturient  women. 

1 135  Spruce  St.  William  H.  Wells,  M.D. 


Vll 


PREFACE  TO  FIRST  EDITION. 


The  design  of  this  book  is  to  furnish  a  useful  compend  and 
Quiz-book  for  the  student,  and  also,  by  the  system  of  question  and 
answer,  to  bring  out  the  more  important  facts  in  Obstetrics  more 
clearly  than  can  be  done  in  the  method  of  continuous  composition. 
On  many  points  it  is  difficult  to  determine  what  is  the  "received 
doctrine,"  except  by  the  mere  numerical  weight  of  authorities. 
The  author  has,  therefore,  attempted  to  maintain  a  judicious 
eclecticism,  instead  of  undertaking  the  task,  impracticable  within 
the  limits  of  the  book,  of  recording  all  the  various  and  more  or  less 
received  teachings  of  all  authors. 

H.  G.  L. 


IX 


TABLE  OF  CONTENTS. 

Page 

Introduction  .  ' i 

The  Pelvis 3 

Bones  of • 3 

Joints  of 6 

Diameters 9 

Planes 11, 12 

Muscles 15 

Reproductive  Organs. 
Anatomy. 

Embryology 16 

Uterus 16 

Ligaments 23,  24 

Fallopian  Tubes 26 

Ovaries 27 

Parovarium    . 29 

Vagina 29 

Douglas'  Cul-de-sac 31 

Hymen 32 

Caruncul^ 33 

Bulb  of  Vagina 33 

Vulvo-vaginal  Glands 34 

Vulva      " 35 

Labia  Majora 35 

Mons  Veneris 35 

Commissures 35 

Fourchette 35 

Clitoris 36 

Labia  Minora 36 

Vestibule 36 

Meatus 36 

Urethra 36 

Perineum 36 

xi 


Xll  CONTENTS 

Page 
Physiology. 

Ovulation 37 

Menstruation 40 

Breasts 43 

Pregnancy 44 

Fecundation 44 

Changes  and  Development  of  Ovum 46 

Nourishment  of  Embryo ■ 49 

Coverings  of  Embryo 50 

Placenta 50 

Fetal  Circulation 52 

Changes  in  Womb 57 

Multiple  Pregnancy 58 

Pathology  of  Pregnancy 60 

Vomiting  of  Pregnancy 60 

Abortion 63 

Premature  Labor 64 

Premature  Detachment  of  the  Placenta 67 

Placenta  Praevia 69 

Extra-uterine  Pregnancy 72 

Varicose  Veins,  Salivation,  etc 79 

Diseases  of  the  Organs  of  Generation 80 

Pruritus  Vulvae 80 

Various  Displacements  of  the  Pregnant  Uterus 81 

Constipation,  etc.,  During  Pregnancy 84 

Nephritis  in  Pregnancy ; 85 

Other  Diseases  Complicating  Pregnancy .  86 

Hydatid  Pregnancy 88 

Chorioepithelioma 90 

Hydramnios,  etc 92 

Signs  of  Pregnancy 93 

Spurious  Pregnancy 96 

Labor. 

Clinical  History .    .  102 

Duties  of  Physician 108 

Mechanism 118 

Pathology  of  Labor. 

Dystocia I43 

Uterine  Inertia I43 

Obstructions  to  Delivery I45 


CONTENTS  Xlll 

Page 

Rigidity  of  Os  Uteri 146 

Tumors 148 

Deformities  of  Pelvis •  149 

Ovular  Dystocia 157 

Effect  of  Maternal  Condition  on  Labor 162 

Twin  Labor    T 167 

Post-partum  Hemorrhage 163 

Rupture  of  Uterus 166 

Eclampsia 167 

Miscellaneous  Complications 171 

Placental  Dystocia 172 

Inversion  of  Uterus  .    .    .    ,' 173 

Obstetric  Operations   . 176 

Forceps 176 

Version 185 

Embryotomy 189 

Abdominal  Cesarean  Section 191 

Vaginal  Cesarean  Section 195 

Porro's  Operation 196 

Celiohysterectomy 197 

Symphysiotomy.   . 197 

Induction  of  Labor 200 

PUERPERIUM. 

Involution  of  Uterus 200 

Secretion  of  Milk  and  Diseases  of  the  Breasts 205 

Puerperal  Septicemia  and  Complications 207 

Newborn  Child. 

Asphyxia  Neonatorum 215 

Congenital  Defects 213 

Ophthalmia  Neonatorum 217 

Umbilicus  and  Diseases  of  the  Umbilicus . 219 

Jaundice  of 221 

Tetanus  of  .- 221 

Appendix  of  Certain  Obstetric  Constants 222 

Index 251 


COMPEND 


OF 


OBSTETRICS 


INTRODUCTION 

What  is  Obstetrics? 

The  science  and  art  of  affording  aid  to  women  in  pregnancy,  child- 
birth, and  the  puerperal  state. 

What  are  the  synonyms  for  obstetrics? 

Midwifery,  accouchement,  maieutics,  tocology. 

What  is  meant  by  science  and  art? 

pjThe  science  of  Obstetrics  embraces  the  definite  rules  of  procedure 
founded  upon  a  correct  knowledge  of  the  anatomy  and  physiology  of 
pregnancy,  labor,  and  the  puerperal  state,  and  of  their  complications; 
the  art  consists  in  the  skilful  carrying  out  of  these  rules.  The  science 
may  be  taught  in  books  and  lectures;  the  art  must  be  acquired  by 
practice  at  the  bedside. 

How  may  the  subject  be  divided? 

1st.  The  Anatomy  of  the  parts  concerned  in  labor,  viz.:  the  repro- 
ductive organs  and  their  surroundings. 

2d.    The  Physiology  of  these  parts. 

3d.  Their  Pathology,  including  all  deviations  from  the  natural 
course  of  pregnancy,  labor  and  the  puerperal  period. 

4th.  The  treatment  of  natura,l  and  complicated  and  the  pathological 
conditions  of  pregnancy,  labor  and  the  puerperal  period. 


2  COMPEND    OF    OBSTETRICS 

What  are  the  reproductive  organs  of  woman? 

1st.  Internal,  viz.:  the  ovaries,  oviducts,  uterus,  and  vagina. 

2d.  External,  viz.:  the  mons  veneris;  labia  majora  and  minora;  cli- 
toris; vestibule  and  fossa  navicularis;  hymen,  or  carunculse  myrti- 
formes;  fourchette  and  perineum;  and  also  the  breasts,  or  mammary 
glands. 


Fig. 


-Vulva  of  a  Virgin. 


.  Labia  majora  of  right  side.  2.  Fourchette.  3.  Labia  minora.  4.  Clitoris. 
5.  Urethral  orifice.  6.  Vestibule.  7.  Orifice  of  the  vagina.  8.  Hymen._  9. 
Orifice  of  vulvo- vaginal  gland.  10.  Anterior  commissure  of  the  labia  majora. 
II.  Orifice  of  the  anus. 


Where  are  they  situated? 

With  the  exception  of  the  breasts  and  mons  veneris,  they  are  placed 
within  the  Pelvis,  or  below  it,  between  the  thighs.  The  mons  veneris 
is  placed  directly  upon  the  symphysis  pubis,  and  the  breasts  on  the 
pectoralis  major  muscle  of  either  side,  from  the  3d  to  the  7th  rib. 


THE    PELVIS  3 

THE  PELVIS 

What' is  the  Pelvis? 

A  bony  structure,  placed  at  the  inferior  extremity  of  the  vertebral 
column,  which  it  supports  above,  while  it  rests  on  the  femora  below. 
It  is  divided  into  the  true  and  false  pelvis. 

Why  is  it  called  the  pelvis? 

Because,  when  clothed  with  muscles,  ligaments,  and  fasciae,  it 
resembles  a  basin. 

Of  how  many  bones  is  the  obstetrical  pelvis  composed? 

Five:  the  last  lumbar  vertebra,  sacrum,  coccyx,  and  two  ossa 
innominata. 

What  is  the  sacrum? 

A  wedge-shaped  bone,  apparently  formed  by  the  fusion  of  five 
vertebrae.     It  is  curved,  being  concave  in  front. 

How  many  articular  surfaces  does  it  present? 

Six:  by  three  it  is  connected  with  the  last  lumbar  vertebra  above; 
by  one  on  each  side,  with  the  ossa  innominata,  and  by  one  below,  with 
the  coccyx. 

What  is  the  coccyx? 

A  small  and  similarly  wedge-shaped  bone,  apparently  formed  by 
the  fusion  of  three  or  four  vertebral  bodies.  It  has  one  articular 
surface  above,  by  which  it  is  connected  with  the  sacrum.  It  tapers 
from  that  bone,  and  is  supposed  to  be  the  remains  of  the  caudal 
vertebrae  of  animals. 

What  are  the  ossa  innominata? 

The  haunch  bones,  of  irregular  shape,  articulating  internally  with 
the  sacrum  behind  and  with  each  other  in  front.  Each  os  innominatum 
is  composed  of  three  separate  pieces,  the  ilium,  ischium,  and  pubes. 
Their  point  of  juncture. is  found  in  a  cup-shaped  depression  on  the 
outside  of  the  bone,  called  the  acetabulum. - 

When  do  the  several  parts  of  the  os  innominatum  unite? 

By  the  the  twenty-fifth  year. 

What  uses  has  the  pelvis? 

1st.  To  support  and  transmit  the  weight  of  the  body. 
2d.    To  contain  and  protect  certain  organs. 


4  COMPEND    OF    OBSTETRICS 

3d.    To  serve  as  a  parturient  tube  or  canal,  through  which  the  child 
may  be  definitely  guided  during  labor. 

To  what  parts  is  the  weight  of  the  body  transmitted? 

To  the  femora  in  the  erect  posture,  and  to  the  tuberosities  of  the 
ischia  in  the  sitting  posture. 

How  is  the  weight  of  the  body  transmitted  to  the  femora? 

By  two  beams  of  bone,  consisting  of  the  upper  part  of  the  sacrum 
and  body  of  the  ilium  on  either  side. 

What  are  these  beams  called? 

The  sacro-iliac  beams  (see  Fig.  2). 


Fig.  2. — B,  with  half  of  A  =  the  left  sacro-iliac  beam,  transmitting  weight  to  the 
femur  F.     C  =  the  body  of  pubes,  constituting  with  its  fellow  the  pubic  beam. 

What  prevents  these  beams  from  being  pushed  in  and  out  at  their 
distal  ends? 

Another  beam  is  placed  between  them,  extending  from  one  acetabu- 
lum to  the  opposite  one,  consisting  of  the  upper  part  of  the  pubes  on 
either  side. 

What  is  this  beam  called? 

The  pubic  beam  (see  Fig.  2). 

Why  are  these  beams  not  straight? 

They  are  arched  outwardly  to  make  more  room  in  the  pelvis,  to 
enable  it  to  fulfil  its  second  and  third,  uses. 


THE    PELVIS 


5 


How  is  the  diminution  in  strength  of  the  sacro-iliac  beams,  caused 
by  this  arching,  remedied? 

By  buttressing  the  beams  by  that. expansion  of  the  sacrum  and  iliac 
bones  called  the  wings  of  the  ilia  and  sacrum  (Fig.  4). 


Fig.  3. — The  same  as  in  Fig.  2,  but  with  the  beams  arched:  the  dotted  lines  show 
the  original  direction  of  force. 


Fig.  4.— The  same  as  in  Fig.  3,  with  the  arches  strengthened  by  the  addition  of 
the  iliac  wings,  etc.  The  dotted  lines  below  show  the  sub-pubic  arch  in  front 
and  the  beginning  of  the  ilio-ischiatic  beams. 

How  are  jarring  and  concussion  prevented? 

By  placing  joints  at  the  center  of  each  beam. 

How  is  the  diminution  of  strength  caused  by  these  joints  remedied? 

By  covering  them  with  powerful  ligaments. 

How  is  weight  transmitted  from  the  vertebral  column  to  the  tuber- 
osities of  the  ischia? 

By  two  beams  of  bone,  placed  directly  under  the  sacro-iliac  beams, 
consisting  of  the  ischium  and  under  portion  of  the  ilium  on  either  side. 


6  COMPEND    OF    OBSTETRICS 

♦ 
What  are  they  called? 

The  ilio-ischiatic  beams. 

How  are  they  held  together  in  front? 

By  another  arched  beam,  placed  directly  under  the  public  beam, 
and  called  the  sub-pubic  beam. 

What  is  the  great  sacro-sciatic  notch? 

The  arched  space  under  the  ilio-ischiatic  beam. 

What  bony  projection  is  found  in  it? 

The  spine  of  the  ischium. 

What  is  the  lesser  sacro-sciatic  notch? 

The  part  of  the  arch  below  the  spine  of  the  ischium. 

What  is  the  obturator  foramen? 

The  space  between  the  pubic  and  sub-pubic  beams  on  either  side. 

How  is  it  closed? 

By  a  membrane  which  gives  attachment  to  muscles. 

How  may  the  female  pelvis  be  distinguished  from  the  male? 

In  the  female,  the  sub-pubic  beam  is  more  roundly  arched  and  its 
edges  more  everted;  the  transverse  diameters  are  relatively  greater, 
and  the  antero-posterior  diameters  relatively  less;  the  transverse 
diameter  of  the  inlet  crosses  the  antero-posterior  at  a  point  in  front 
of  the  intersection  of  the  oblique  diameters,  and  the  ischial  spines 
are  to  the  outer  side  of  plumb  lines  dropped  from  the  posterior  supe- 
rior iliac  spines.  (Some  female  pelves,  especially  among  the  lower 
races,  approach  the  male  type.)     See  Fig.  5. 

What  joints  exist  in  the  pelvis? 

Three  lumbo-sacral  above  (one  between  the  bodies  and  two  be- 
tween the  articular  processes),  two  sacro-iliac  (one  on  either  side), 
the  pubic  joint,  in  front,  and  the  sacro-coccygeal  joint,  behind. 

What  are  the  pelvic  joints  called? 

Symphyses,  and  the  pubic  joint  is  often  called,  by  way  of  distinc- 
tion, the  symphysis. 

What  kind  of  joints  are  they? 

Amphiarthrodial,  with  the  exception  of  those  formed  by  the  artic- 
ular processes  of  the  sacrum  and  last  lumbar  vertebra,  which  are 


THE    PELVIS  7 

arthrodial,  and  are  lined  by  synovial  membranes.  The  sacro- coccy- 
geal joint  is  always  freely  movable,  and  has  a  demonstrable  synovial 
sac;  the  other  joints  can  only  be  shown  to  have  sacs  during  pregnancy. 

What  is  the  sacral  promontory? 

The  projection  or  angle  formed  by  the  top  of  the  sacram  in  front 
at  its  junction  with  the  vertebra  above.  It  is  often  called  simply 
the  promontory.  ^ 


Fig.  s- 


What  is  the  ilio -pectineal  line? 

A  bony,  ridge  or  raised  line,  which,  beginning  at  the  promontory, 
extends  around  each  side  of  the  pelvis,  within,  until  it  meets  the 
opposite  line  at  the  symphysis  pubis. 

What  are  the  synonyms  for  the  ilio-pectineal  line? 

The  superior  strait,  the  pelvic  inlet,  margin,  brim,  isthmus,  linea 
terminale,  linea  ilio-pectinea,  the  pelvic  inlet. 

What  is  meant  by  the  anatomical  inlet? 

This  is  the  entrance  of  the  small  or  true  pelvis  and  corresponds 
to  the  upper  margin  of  the  symphysis  pubis  and  to  the  edges  of  the 
bones  extending  backward  to  the  sacral  promontory. 

What  is  the  obstetric  inlet? 

This  is  the  least  available  space  at  the  upper  position  of  the  pelvic 
canal;  it  is  bounded  by  a  line  passing  about  i  inch  below  the  upper 


8  COMPEND    OP    OBSTETRICS 

margin  of  the  symphysis  pubis;  along  the  posterior  margin  of  the 
obHque  rami  and  body  of  the  pubis,  past  the  iHo-pectineal  eminences, 
the  anterior  margin  of  the  sacral  alas,  and  the  summit  of  the  sacral 
promontory.     (Edgar.) 

What  anatomical  landmarks  are  found  on  the  pelvic  inlet? 

1.  The  symphysis  pubis  in  front. 

2.  Posterior  on  either  side  of  the  pubic  bone,  close  to  the  ilio-pubic 
junction — the  ilio-pectineal  eminence  on  either  side. 

3.  Ilio-pectineal  line. 

4.  Sacro-iliac  joints. 

5.  The  intra -vertebral  cartilage  between  the  last  lumbar  vertebra  and 
the  sacrum. 

What  is  the  shape  of  the  pelvic  inlet? 

The  shape  of  the  inlet  of  the  bony  pubis  is  that  of  a  curvilinear 
triangle  with  the  base  behind  and  the  apex  in  front,  the  chief  irregu- 
larity being  at  the  sacral  promontory. 

What  is  the  ilio-pectineal  line  said  to  bound? 

The  inlet  of  the  pelvis,  because  the  child  must  first  enter  the  pelvis 
through  this  bony  ring. 

What  parts  lie  above  the  ilio-pectineal  line? 

The  wings  of  the  sarcum,  iliac  fossae,  and  crests,  and  the  last  lumbar 
vertebra  forming  the  bony  parts,  or  the  false  pelvis. 

What  are  the  boundaries  of  the  false  pelvis? 

The  false  pelvis,  also  known  as  the  superior  or  large  pelvis  is  bounded 
behind  by  the  last  lumbar  vertebra  and  the  ilio-lumbar  ligaments. 
On  the  sides  by  the  iliac  bones.  In  front  there  are  no  bones  but  this 
space  is  filled  in  the  living  subject  by  the  elastic  lower  abdominal  wall, 
below  it  bounded  by  the  superior  strait.  The  outward  curve  of  the 
iliac  bones  is  known  as  the  flare  of  the  pelvis.  If  the  convergence 
of  the  bony  walls  of  the  false  pelvis  were  continued  downward,  they 
would  meet  at  a  point  corresponding  with  the  fourth  sacral  vertebra. 

What  lies  below  it? 

The  true  or  obstetric  pelvis. 

What  are  the  boundaries  of  the  true  pelvis  or  pelvic  cavity? 

The  true  pelvis  also  known  as  the  inferior  or  small  pelvis  is  bounded 
above  by  the  superior  strait,  posteriorly  by  the  concavity  of  the  sacrum 


THE    PELVIS  9 

and  coccyx,  on  the  sides  by  the  sacro-iliac  Hgaments,  the  innominate 
bones,  the  internal  surfaces  of  the  acetabula  and  obturator  mem- 
branes, anteriorly  by  the  pubic  bones  and  the  obturator  membranes, 
inferiorly  it  is  bounded  by  the  pelvic  outlet.  If  any  horizontal 
plane  of  this  curved  cylinder  of  the  true  pelvis  is  taken  at  a  level, 
the  bony  wall  is  incomplete.  In  any  plane  selected  there  may  be 
a  foramen  covered  by  membrane  or  by  distensible  and  elastic  mus- 
cular or  fibrous  tissue  or  a  movable  joint  such  as  the  coccyx  directly 
opposite  the  solid  mass  of  the  pubic  bones;  or  some  elastic  tissue 
that  will  permit  of  considerable  compression  without  injury.  This 
arrangement  is  to  prevent  too  great  or  prolonged  pressure  on  the 
fetus  during  birth. 

What  is  the  pectineal  eminence? 

The  point  in  the  ilio-pectineal  line  which  is  opposite  the  acetabulum, 
and  is  slightly  raised  above  the  ordinary  level  of  the  line. 

What  is  the  ilio-ischiatic  line? 

A  slightly  raised  ridge,  on  the  inside  of  the  pelvis,  which  begins 
at  the  pectineal  eminence  and  ends  in  the  ischiatic  spine  on  either 
side. 

What  are  the  cardinal  points  of  Capuron? 

The  sacro-iliac  joints  and  ilio-pectineal  eminences. 

What  are  the  diameters  of  the  pelvis? 

Lines  drawn  from  various  points  of  the  pelvic  inlet,  pelvic  cavity 
and  outlet  to  facilitate  the  description  of  the  relations  which  the 
child's  surface  bears  to  the  pelvis  during  its  passage  through  it. 

What  are  the  diameters  of  the  inlet? 

The  antero-posterior  or  conjugate,  two  oblique,  and  the  transverse. 

What  is  the  conjugate  (or  sacro- suprapubic)  diameter  of  the  inlet? 

A  line  drawn  from  the  promontory  of  the  sacrum  to  the  top  of  the 
symphysis  pubis.  It  is  about  41/2  inches,  or  11.5  centimeters. 
The  sacro-pubic  diameter  or  true  conjugate  is  taken  from  the  prom- 
ontory of  the  sacrum  to  the  middle  of  the  posterior  surface  of  the 
pubic  joint.  Its  measurement  is  about  the  same  as  the  above. 
The  sacro-sub-pubic  diameter  is  taken  from  the  same  point  behind 
to  the  inferior  surface  of  the  pubic  joint.  Its  length  is  13.5  centi- 
meters, or  5.3  inches. 


lO  COMPEND    OF    OBSTETRICS 

What  are  the  oblique  diameters? 

Lines  drawn  from  the  sacro-iliac  symphysis  of  either  side  to  a 
point  in  front  of  the  pectineal  eminence  of  the  opposite  side  (Meadows). 
The  one  drawn  from  the  right  sacro-iHac  symphysis  is  called  the 
right  oblique;  the  one  from  the  left  symphysis,  the  left  oblique.  They 
are  about  5.3  inches,  or  13.5  centimeters. 

"What  is  the  transverse  diameter  of  the  inlet? 

A  line  drawn  directly  across  the  pelvic  inlet  from  one  pectineal 
eminence  to  the  other.  In  the  normal  pelvis  it  is  about  4.8  inches  or 
12.5  centimeters. 

What  is  the  circumference  of  the  pelvic  inlet? 

About  15.8  inches,  or  40  centimeters. 

What  is  the  depth  of  the  pelvic  cavity? 

One  and  one-half  inches,  or  3.8  centimeters  in  front;  31/2  inches, 
or  8.9  centimeters  at  sides;  posteriorly,  41/4  inches,  or  10.8  centi- 
meters, or  following  the  curve  of  the  sacrum,  it  is  about  51/2  inches, 
or  13.8  centimeters.  The  average  diameters  are  about  4  3/4  to  5 
inches,  or  12  centimeters. 

What  obstetric  landmarks  are  found  in  the  pelvic  cavity  or  true 
pelvis? 

1.  The  pubic  joint  in  front. 

2.  The  obturator  foramen. 

3.  The  spine  of  the  ischium. 

4.  The  great  sacro- sciatic  foramen  and  ligaments. 

5.  The  lesser  sacro- sciatic  foramen  and  ligaments.    . 

6.  The  sacrum  and  coccyx. 

Where  is  the  pelvic  outlet? 

It  is  bounded  by  the  tip  of  the  coccyx  behind,  by  the  tuberosities 
of  the  ischia  on  the  sides,  and  by  the  sub-pubic  arch  in  front.  It  is 
called  also  the  inferior  strait. 

What  are  the  diameters  of  the  outlet? 

The  conjugate  and  transverse. 

What  is  the  conjugate  diameter  of  the  outlet? 

A  line  drawn  from  the  tip  of  the  coccyx  to  the  under  edge  of  the 
symphysis  pubis.  It  is  of  variable  length,  owing  to  the  mobility  of 
the  coccyx,  but  when  the  latter  is  extended,  during  labor,  it  is  the 


THE    PELVIS 


II 


longest  diameter  of  the  outlet,  and  may  measure  5  inches,  or 
about  15  centimeters;  ordinarily  it  measures  about  4.3  inches,  or  11 
centimeters. 

What  is  the  transverse  diameter  of  the  outlet? 

A  line  drawn  from  one  tuberosity  of  the  ischium  to  the  opposite 
one,  and  measures  about  4  inches,  or  11  centimeters  in  the  normal 
pelvis.  The  circumference  of  the  outlet  is  18  inches  or  about  45 
centimeters. 


Fig.  6. 


What  are  the  obstetric  landmarks  on  the  pelvic  outlet? 

From  before  backward. 

1.  The  pubic  arch  and  sub-pubic  ligament. 

2.  Descending     ramus    of    the  pubis  and    ascending    ramus    of  the 
ischium. 

3.  Tuberosity  of  the  ischium. 

4.  The  spine  of  the  ischium. 

5.  The  greater  and  lesser  sacro- sciatic  ligament. 

6.  The  coccyx. 

What  are  the  planes  of  the  pelvis? 

Imaginary  levels,  drawn  through  any  part  of  the  pelvic  circum- 
ference (Playfair),  to  facilitate  the  description  of  the  relations  of 
the  pelvis  to  the  child,  vertebral  column,  or  horizon.  They  may  be 
illustrated  by  pieces  of  card-board  cut  so  as  to  fit  the  pelvic  cavity  at 
any  level. 


12 


COMPEND    OF    OBSTETRICS 


What  planes  are  important? 

The  plane  of  the  inlet,  of  the  cavity  and  of  the  outlet. 

What  is  the  plane  of  the  inlet? 

A  plane  drawn  transversely  through  the  conjugate  diameter  of  the 
inlet,  and  limited  by  the  circumference  of  the  inlet.  The  plane  of 
the  obstetric  inlet  would  be  represented  by  a  piece  of  card-board  that 

so  fitting  the  entrance  of 
the  pelvis  that  its  margins 
corresponded  to  the  base 
of  the  sacrum,  the  ilio- 
pectorial  line  and  the 
posterior  surface  of  the 
symphysis  pubis  along  a 
transverse  Hne  2/3  inch 
(i  cm.)  below  its  upper 
margin  (Edgar).  It  does 
not  coincide  with  the 
anatomical  conjugate 
diameter  of  the  anatomi- 
—        ,-  -,. . .  cal  inlet. 


Fig.  7. — a  b.  Conjugate  diameter  of  inlet,  e  f. 
Conjugate  diameter  of  outlet,  g  k.  Axis  of 
pelvic  cavity  or  curve  of  Cams. 


What   is    the   plane  of 
the  pelvic  cavity? 

A  plane  extending  from 
the  middle  of  the  poste- 
rior surface  of  the  the  symphysis  pubis,  over  the  central  point  of  the 
internal  surfaces  of  the  acetabular  cavities,  to  the  upper  margin  of  the 
third  piece  of  the  sacrum. 

What  is  the  plane  of  the  outlet? 

A  plane  drawn  transversely  through  the  conjugate  diameter  of  the 
outlet,  and  limited  by  the  circumference  of  the  outlet. 

How  are  these  planes  used  to  show  the  position  of  the  pelvis 
in  different  postures? 

In  the  erect  posture  the  plane  of  the  inlet  makes  an  angle  of  60° 
with  the  horizon.  In  the  semi-recumbent  posture  the  same  plane  is 
directly  horizontal,  and  in  the  recumbent  posture  it  forms  a  reversed 
angle  of  45°  with  the  horizon.  The  plane  of  the  parturient  outlet  is 
below  the  plane  of  the  bony  outlet  and  corresponds  with  the  vulvo- 
vaginal ring.     It  is  nearly  parallel  with  the  long  axis  of  the  mother's 


THE    PELVIS 


13 


14 


COMPEND    OF    OBSTETRICS 


body  and  when  the  woman  is  in  the  dorsal  position  looks  almost 
directly  upward. 


Fig.  9, — Axes  of  the  Pelvis  in  Relation  to  the  Perpendicular-  of  the 

Body. 


What  is  the  axis  of  the  pelvis? 

As  usually  given  it  is  a  line  drawn  from  the  center  of  the  con- 
jugate diameter  of  the  inlet,  parallel  to  the  face  of  the  sacrum  and 


THE    PELVIS  «  15 

coccyx,  to  the  center  of  the  conjugate  diameter  of  the  outlet  (Figs. 
7,  8,  9).  • 

What  other  name  is  sometimes  given  to  the  axis  of  the  pelvis? 

The  curve  or  circle  of  Carus  (see  g  k,  Fig.  7). 

What  is  the  obliquity  of  the  pelvis? 

The  planes  of  the  pelvis  and  the  spinal  column  stand  in  the  relation 
of  an  obtuse  angle;  this  is  the  obliquity  of  the  pelvis. 

How  is  the  pelvis  lined  within? 

By  certain  muscles,  blood-vessels,  nerves,  and  fasciae. 

What  muscles  are  contained  in  it? 

1.  The  Psoas  iliacus  muscle  on  either  side,  consists,  first,  of  the 
iliacus  internus,  which,  in  its  origin,  covers  almost  the  entire 
inner  aspect  of  the  wing  of  the  iUum,  uniting  with  the  psoas  magnus, 
which  passes  over  the  upper  border  of  the  sacrum.  Their  con- 
joined body  passes  along  the  border  of  the  sacro-iliac  arch,  and  by 
common  tendon  passes  out  of  the  pelvis,  between  the  anterior 
inferior  iliac  spine  and  the  ilio-pectineal  eminence,  to  be  inserted 
upon  the  femur. 

2.  The  Pyriformis  muscle  on  either  side,  which  covers  with  its  inser- 
tion the  face  of  the  sacrum,  and  passes  out  of  the  pelvis  under  the 
sacro-ischiatic  arch,  to  be  inserted  upon  the  femur. 

3.  "The  Obturator  internus  muscle  on  either  side,  which  covers  the 
anterior  pelvic  walls  and  passes  out  under  the  sacro-ischiatic  arch. 

What  obstetric  uses  have  these  muscles? 

Besides  serving  as  a  soft  lining  to  the  bones,  the  psoas  iliacus 
furnishes  a  cushion,  or  guard,  for  the  iliac  vessels  and  nerves,  preserv- 
ing them  from  pressure,  while  the  pyriformis  performs  the  same  office 
for  the  sciatic  nerve,  which  lies  along  its  border. 

What  modifications  are  produced  in  the  bony  pelvis  by  the  soft 
parts? 

They  lessen  the  pelvic  diameters  and  the  depth  of  the  iliac  fossae. 
The  obHquity  of  the  iliac  bones  is  also  decreased  on  their  inner  surface. 

How  are  the  diameters  of  the  pelvis  modified  by  the  soft  parts? 

The  transverse  diameter  of  the  inlet  is  decreased  from  one-half 
to  three-quarters  of  an  inch  by  the  ilio-psoas  muscles;  both  oblique 
diameters  are  lessened  one-eighth  of  an  inch,  while  the  left  oblique 


i6 


•  COMPEND    OF    OBSTETRICS 


is  still  further  decreased  by  the  rectum.  The  iHacus  muscles  lessen 
the  depth  of  the  iliac  fossae,  while  the  obHquity  of  the  iHa  is  made  less 
by  the  psoas  muscles. 

THE  REPRODUCTIVE  ORGANS 

THE  INTERNAL  ORGANS 

From  what  are  the  internal  reproductive  organs  developed? 
From  the  Wolffian  bodies,  which  are  two  glandular  bodies  existing 


Fig.  10. — A.  Fundus.  B.  Cavity  of  uterus.  C.  Internal  os.  D.  Fallopian  tubes 
or  oviducts.  E.  Fimbriated  extremity,  p.  Ovary.  C.  Round  ligament.  H. 
Ligament  of  ovary.  I.  Tubo-qvarian  ligament.  J.  External  os.  O.  Cavity  of 
cervix,  showing  rugae.     V.  Vagina,     b.   Mouths  of  oviducts. 


one  on  either  side  of  the  spinal  column  during  embryonic  life.  The 
Wolffian  bodies  are  also  known  as  the  false,  primitive,  or  primordial 
kidneys  or  the  kidney  of  Oken. 

Of  what  do  the  Wolffian  bodies  consist? 

Each  is  composed  of  a  series  of  fine  tubes  emptying  into  a  common 
excretory  duct  known  as  the  Wolffian  duct. 

What  are  Miiller's  ducts? 

These  are  two  in  number,  one  for  each  Wolffian  body  being  devel- 
oped on  their  outer  surface.  From  them  are  derived  the  oviducts, 
uterus,  and  vagina. 

What  and  where  is  the  Uterus? 

The  uterus  or  womb  is  a  hollow  muscular  organ,  situated  in  the 
center  of  the  pelvis,  between  the  bladder  and  the  rectum. 


THE    REPRODUCTIVE    ORGANS 


17 


What  are  its  shape  and  dimensions? 

It  somewhat  resembles  a  pear,  the  anterior  surface  being  flat,  while . 
the  posterior  surface  is  rounded.     In  the  unimpregnated  state  it  is 
about  3  inches  long,  2   inches  broad  at  the  broadest   part   of   the 
body  or  corpus  and  at  the  same  point  about  i  inch  thick  antero- 
posteriorly.     Its  weight  in  the  virgin  is  approximately  r  ounce. 

Into  what  parts  is  it  divided? 

Into,  first,  the  cervix,  or  neck,  about  an  inch  long;  and  second,  the 
body  or  fundus. 

What  are  the  cornua  of  the  uterus? 

The  upper  and  outer  angles  are  called  the  cornua. 

How  is  the  cavity  of  the  uterus  divided? 

Into  the  cavities  of  the  cervix  and  body. 
The  first  is  fusiform,  and  appears  to  be  an 
ante-chamber  to  the  main  cavity;  the  latter 
is  triangular  in  outline,  but  with  its  walls  in 
apposition  (see  Fig.  11).  \JiM^lig:^/-Jiwl  C 

What  openings  are  found  in  the  cervix? 

The  OS  externum,  external  os,  or  os  uteri, 
called  also  the  os  (J,  Fig.  10),  is  a  small  open- 
ing into  the  cavity  of  the  cervix  at  its  lower 
end.  The  constriction  between  the  cavities 
of  the  ncek  and  body  is  called  the  os  inter- 
num or  internal  os  (C,  Fig.  10). 

What  is  the  contraction  ring  of  Bandl? 

This  is  a  line  of  depression  sometimes  felt 
on  digital  pressure  just  above  the  pubes.     It 
corresponds  to  the  site  of  the' internal  os  and  can  only  be  felt  during 
labor  pains  (see  Fig.  12). 

What  is  the  structure  of  the  uterus? 

It  is  mainly  composed  of  muscular  tissue,  for  the  most  part  of  the 
unstriped  variety,  with  fibrous  connective  tissue,  blood-vessels,  and 
nerves.  On  the  outside,  it  is  nearly  covered  with  peritoneum,  and 
on  the  inside,  is  lined  with  mucous  membrane,  called  the  endometrium. 

How  are  the  muscular  fibers  arranged? 

For  the  most  part  they  are  irregularly  and  inextricably  interlaced 
and  surround  the  large  blood-vessels  which  penetrate  between  them, 
2 


Fig.  II. — Antero-poste- 
RiOR  Section  of  Adult 
Uterus. 


COMPEND    OF    OBSTETRICS 


THE    REPRODUCTIVE    ORGANS  1 9 

but  a  circular  arrangernent  of  fibers  is  found  in  the  cervix,  and  to  a 
certain,  extent  around  the  openings  of  the  Fallopian  tubes,  while  in 
the  body  the  majority  are  longitudinal.  The  longitudinal  fibers 
aid  greatly  in  dilating  the  cervix  and  retracting  it  over  the  presenting 
part  of  the  fetus.  A  middle  layer  of  oblique  fibers  is  also  described; 
these  latter  aid  materially  in  the  expulsive  power  of  the  organ. 

What  is  the  blood  supply  of  the  uterus? 

The  arterial  supply  is  prinicpally  from  the  uterine  and  to  a  lesser 
extent  from  the  ovarian  arteries.  The  uterine  artery  is  the  main 
branch  of  the  hypogastric,  which,  descending  a  short  distance  from  its 
origin  enters  the  base  of  the  broad  ligament,  crosses  the  ureter  and 
makes  its  way  to  the  side  of  the  uterus.  Just  before  reaching  the 
supravaginal  portion  of  the  cervix  it  divides  into  a  larger  and  a 
smaller  branch — the  smaller — the  cervico-vaginal  artery  supplying  the 
lower  portion  of  the  cervix  and  the  upper  portion  of  the  vagina.  The 
main  branch  turns  abruptly  upward  and  extends  as  a  very  conviiluted 
vessel  along  the  upper  margin  of  the  uterus  giving  off  a  branch  of 
considerable  size  to  the  upper  portion  of  the  cervix  and  numerous 
smaller  ones  which  penetrate  the  body  of  the  uterus.  Just  before 
reaching  the  tube  it  divides  into  three  terminal  branches — the  fundal, 
tubal  and  ovarian — the  last  of  which  anastomoses  with  the  terminal 
.  branch  of  the  ovarian  artery;  the  second  making  its  way  through  the 
mesosalpinx,  supplies  the  tube  and  the  fundal  branch  is  distributed 
to  the  upper  portion  of  the  uterus.  The  ovarian  or  internal  spermatic 
artery  is  a  branch  of  the  aorta  and  enters  the  broad  ligament  through 
the  infundibulo  pelvic  ligament.  On  reaching  the  hilum  of  the  ovary 
it  breaks  up  into  a  number  of  small  branches  which  enter  the  organ 
while  its  main  stem  traverses  the  entire  length  of  the  broad  hgament 
and  makes  its  way  to  the  upper  portion  of  the  margin  of  the  uterus, 
when  it  anastomses  with  the  ovarian  branch  of  the  uterine  artery. 
(Williams  Obstetrics.) 

Is  there  any  connection  or  anastomsis  between  the  circulation  of 
both  sides  of  the  uterus? 

The  experiments  of  Clark  have  shown  that  when  the  uterine  artery 
on  one  side  was  injected  with  fluid  the  latter  escaped  from  the  oppo- 
site uterine  artery  before  it  began  to  flow  from  the  veins  showing 
the  presence  of  numerous  arterial  anastomoses  in  the  substance- of 
the  uterus. 


20  COMPEND    OF    OBSTETRICS 

Describe  the  venous  or  retiirn  circulation  of  the  uterus. 

The  veins  from  the  uterus  form  an  abundant  plexus  around  each 
uterine  artery  and  unite  to  form  the  uterine  vein  on  either  side,  which 
then  empties  into  the  hypogastric  vein.  This  In  turn  empties  with  the 
internal  iliac.  The  blood  from  the  ovary  and  upper  part  of  the  broad 
ligament  is  collected  by  a  number  of  veins  which  form  a  large  plexus 
within  the  broad  ligament — the  Pampiniform  Plexus — the  vessels 
from  which  terminate  in  the  ovarian  vein.  The  right  ovarian  vein 
empties  into  the  vena  cava  while  the  left  empties  into  the  renal  vein. 

How  is  the  uterus  supplied  with  Nerves? 

The  nerve  supply  of  the  uterus  is  derived  mainly  from  the  sym- 
pathetic system.  Although  the  cerebrospinal  system  bears  a  part. 
The  latter  is  represented  by  fibers  derived  from  the  3rd  and  4th  sacral 
nerves  and  Herlizka  (Williams)  has  demonstrated  the  presence  of 
medullated  nerve  fibers  in  the  uterine  wall,  which  showed  free  endings 
between  the  muscle  bundles.  According  to  Herff  and  Gawronsky 
ganglionic  cells  exist  in  the  muscular  coat  also. 

The  greater  portion  of  the  nerve  supply  is  derived  from  the  sym.- 
pathetic  system.  According  to  Frankenhaeuser,  Lee,  Rein  and  Pes- 
semski  large  nerve  trunks  from  the  inner  iliac  plexus  pass  down  on 
either  side  of  the  rectum,  and  following  the  course  of  the  utero-sacral 
ligaments  terminate  in  the  large  cervical  ganglion.  Keiffer  has  shown 
that  small  but  definite  ganglia  are  present  in  the  course  of  th-e  nerves, 
especially  where  various  branches  cross  one  another. 

How  is  the  uterus  supplied  with  Lymphatics? 

The  endometrium  is  abundantly  supplied  with  lymph  spaces  but 
possesses  no  lymphatic  vessels.  (Leopold,  Poirrier,  etc.,  quoted  from 
Williams.)  Immediately  beneath  it  in  the  muscular  coat  a  few  lym- 
phatics may  be  found  which  become  better  defined  as  the  peritoneum 
is  approached  and  form  an  abundant  lymphatic  plexus  just  beneath  it, 
which  is  especially  marked  on  the  posterior  or  intestinal  wall  of  the 
uterus.  The  lymphatics  from  the  various  portions  of  the  uterus  are 
connected  with  several  sets  of  glands. 

1.  Those  from  the  cervix  terminating  in  the  hypogastric  glands 
which  are  situated  in  the  spaces  between  the  external  iliac  and 
hypogastric  arteries. 

2.  The  lymphatics  from  the  body  of  the  uterus  are  distributed  to 
two  groups  of  glands — one  set  making  their  way  to  the  hypo- 
gastric glands,  while  another  set  after  joining  certain  lymphatics 


THE    REPRODUCTIVE    ORGANS 


21 


for  the  ovarian  region  terminate  in  the  lumbar  glands  which  are 
situa{ed  in  front  of  the  aorta  at  about  the  level  of  the  lower  portion 
of  the  kidneys. 

What  kind  of  mucous  membrane  lines  the  uterus? 

The  membrane  lining  the  body  is  pinkish  in  color,  quite  thick  and 
vascular,  and  is  -composed : 


Fig.  13 — Scheme    of  the  Ovarian  and    Uterine,   Vaginal   Arteries. — (From 

Morris'  Anatomy.) 

I.  Uterine  branch  of  ovarian  artery.  2.  Branch  to  round  ligament,  3.  Branches 
to  isthmus.  4.  Branch  to  ampulla.  5.  Fimbriated  extremity  of  Fallopian  tube. 
6.  Cervical  branch  of  uterine  artery.  7.  Coronal  artery.  8.  Ovarian  artery. 
9.  Ovarian  branches.  10.  Uterine  artery.  11.  Internal  iliac  artery.  12.  Vaginal 
arteries.      13.  Azygos  artery  of  vagina. 

1.  Of  a  mesh  of  connective  tissue  containing  many  spindle-shaped 
cells. 

2.  Of  many  tubular  glands,  which  give  the  surface  of  the  membrane 
a  perforated  appearance. 

3.  Of  ciliated  cylindrical  epithelium,  which  lines  the  glands  and  the 
outer  surface  of  the  whole  membrane. 


22 


COMPEND    OF    OBSTETRICS 


The  membrane  lining  the  cervix  is  continuous  with  that  of  the 
body  of  the  uterus,  and  is  substantially  the  same  except  that  it  is 
thrown  into  numerous  longitudinal  folds  with  lateral  branches — 
the  "arbor  vitae "  of  the  cervix.  The  epithelial  cells  in  the  upper  two- 
thirds  of  the  cervical  canal  are  columnar,  ciliated;  in  the  lower  4;hird, 
stratified,  squamous  cells.  In  addition  to  the  tubular  glands  of  the 
uterine  bod}^,  the  cervical  mucous  membrane  contains  wide  mucous 
crypts. 


Fig.  14. — Lymphatics  of  the  Uterus. — {Poirier.) 

I.  Lympliatics  from  the  body  and  fundus  of  the  uterus.  2.  Ovary.  3.  Vagina. 
4.  Fallopian  tube.  5.  Lymphatics  from  the  cervix.  _  6.  Lymphatics  going  from 
the  cervix  to  the  lymphatic  ganglia.  7,7.  Lymphatics  going  from  the  body  and 
fundus  to  the  lumbar  ganglia.  8.  Anastomosis  of  corporeal  and  cervical  vessels. 
9.  Small  lymphatic  in  round  ligament  going  to  the  inguinal  glands,  10,  11 
Lymphatic  vessels  of  the  tubes  emptying  into  the  large  lymphatic  vessels  from 
the  body  of  the  uterus.      12.  Ovarian  ligament. 

What  distinguishing  peculiarity  has  the  uterine  mucous  membrane? 

It  has  no  basement  layer  of  connective  tissue  (sub mucosa),  and 
merges  irregularly  into  the  muscular  tissue. 

What  kind  of  mucus  is  secreted  by  the  uterine  mucous  membrane? 

A  viscid,  alkaline  mucus. 

What  are  ovula  Nabothi? 

These  are  racemose  glands  or  crypts  in  the  cervical  mucous  mem- 


THE    REPRODUCTIVE    ORGANS  23 

brane  which  sometimes  become  occluded,  while  the  secretion  con- 
tinues until  the  gland  becomes  quite  large  and  globular.  They  are 
frequently  seen  in  cases  of  chronic  inflammation  of  the  cervix  and  are 
often  a  source  of  much  irritation. 

How  does  the  peritoneum  coyer  the  uterus? 

It  completely  invests  the  uterus  above,  in  front  as  far  as  the 
junction  of  the  body  and  cervix,  where  the  "bladder  touches  the 
womb,  and  behind  as  far  as  the  junction  of  the  uterus  and  vagina, 

What  is  the  broad  ligament  of  the  uterus  or  ligamentum  lata? 

The  extension  of  the  peritoneum  over  the  uterus  causes  two  folds 
of  peritoneum  to  be  brought  together  at  its  sides,  and  these  extend 
across  the  pelvis,  to  be  merged  into  the  common  abdominal  peri- 
toneum. These  transverse  folds,  enclosing  muscular  and  fibrous 
tissues,  blood-vessels,  nerves,  and  lymphatics,  are  called  the  broad 
ligaments,  and  divide  the  pelvis  into  two  compartments;  in  the 
anterior  one  the  bladder  is  situated,  in  the  posterior,  the  rectum. 
The  inner  two-thirds  of  the  superior  margin  of  the  broad  ligament 
serves  to  transmit  the  Fallopian  tube  or  oviduct.  The  portion  of  the 
broad  ligament  beneath  the  Fallopian  tube  is  called  the  Mesosalpinx. 
It  consists  of  two  layers  of  peritoneum  which  are  united  by  a  small 
amount  of  loose  connective  tissue  in  which  is  imbedded  the  parovarian 
or  organ  of  RosenmuUer.  At  its  lateral  margin  the  peritoneum  covering 
the  broad  ligament  is  reflected  upon  the  side  of  the  pelvis.  The 
inferior  margin  which  is  somewhat  thick  is  continuous  with  the  connect- 
ive tissue  of  the  pelvic  floor.  Through  it  pass  the  uterine  vessels. 
The  lower  portion  somtimes  known  as  the  cardinal  ligament  of  Kocks 
or  the  ligamentum  transversale  colli  of  Mackenrodt  or  the  retinaculum 
uteri  of  Martin  is  composed  of  dense  connective  tissue  which  is  firmly 
united  to  the  supravaginal  portion  of  the  cervix.  The  median  margin 
is  connected  with  the  lateral  margin  of  the  uterus  and  encloses  the 
uterine  vessels.  Through  it  certain  muscular  and  connective-tissue 
bands  extend  from  the  uterus  to  the  broad  ligament.  A  vertical 
section  through  the  uterine  end  of  the  broad  ligament  will  show  it  to  be 
triangular  in  shape  with  the  apex  above,  while  its  base  is  broad  and 
contains  the  uterine  vessels.  Its  connective  tissue  is  connected  with  the 
connective  tissue  of  the  pelvic  floor  and  lying  behind  the  bladder: 
This  is  called  the  parametrium.  Vertical  section  through  the  middle 
portion  of  the  broad  ligament  shows  that  its  upper  part  is  composed 
mainly  of  three  branches  in  which  the  Fallopian  tube,  ovary  and  round 


24  COMPEND    OF    OBSTETRICS 

ligament  are  situated  while  its  lower  portion  is  not  so  thick  as  the  first 
section. 

What  are  the  round  ligaments? 

They  are  two  rounded  cords,  composed  of  fibrous  tissue,  inter- 
spersed with  muscular  fibers,  which  extend  underneath  the  peri- 
toneum, from  the  cornua  of  the  uterus  to  the  top  of  the  pelvis  in  front, 
where  they  pass  through  the  inguinal  canal  to  be  inserted  in  the  con- 
nective tissue  of  the  labia  majora.  The  term  ligamenta  teretia  is 
sometimes  applied  to  the  round  ligaments. 

What  are  the  infundibulo  pelvic  ligaments? 

These  are  the  suspensory  ligaments  of  the  ovaries,  one  on  either  side. 
It  is  really  the  outer  third  of  the  superior  margin  of  the  broad  ligament. 
It  extends  from  the  fimbriated  extremity  of  the  Fallopian  tube  to  the 
pelvic  wall.     It  serves  to  transmit  the  ovarian  vessels. 

What  are  the  utero -sacral  ligaments? 

Bands  of  fibrous  tissue  which  pass  from  either  side  of  the  uterus 
to  the  sacrum,  and  are  of  considerable  strength.  They  are  sometimes 
termed  the  retractores  uteri.  They  extend  from  the  posterior  and 
upper  portion  of  the  cervix  and  encircle  the  rectum  and  are  inserted 
into  the  fascia  covering  the  second  and  third  sacral  vetebra.  They 
are  composed  of  connective  tissue,  some  muscular  fibers  and  are 
covered  by  peritoneum.  They  form  the  lateral  boundaries  of  Douglas 
cul-de-sac. 

What  are  the  vesico -uterine  ligaments? 

Small  folds  of  peritoneum  which  pass  between  the  uterus  and  the 
bladder. 

What  is  the  normal  position  of  the  uterus? 

The  uterus  is  placed  nearly  in  the  center  of  the  pelvis;  so  that  a 
line  drawn  from  the  top  of  the  symphysis  to  the  middle  of  the  second 
bone  of  the  sacrum  would  touch  its  top.  Its  long  axis  is  nearly  parallel 
to  the  face  of  the  sacrum  and  to  the  posterior  wall  of  the  symphysis 
pubis.  The  uterus  is  freely  movable,  and  ist,  rises  and  falls  with 
the  respiratory  movements,  and  2nd,  is  pushed  backward  and  for- 
ward by  the  varying  conditions  of  fulness  in  the  bladder  and  rectum. 

What  supports  the  uterus? 

1st.     The  uterus   is   swung   from  the   sacrum   by   the   utero-sacral 
ligaments. 


THE    REPRODUCTIVE    ORGANS 


25 


2d.  It  is  slightly  supported  or  belayed  by  the  broad,  round,  vesico- 
uterine ligaments. 

3d.  The  walls  of  the  vagina  act  as  a  fleshy  column  of  support,  being 
in  turn  supported  by  the  perineum. 

4th.  "The  retentive  power  of  the  abdomen"  (Duncan),  due  to 
the  existence  of  a  partial  vacuum  in  the  abdominal  cavity,  aids 
in  maintaining  {he  uterus  in  its  normal  position. 

What  is  a  double  uterus? 

A   uterus    containing   two    cavities   separated   by   a   longitudinal 
septum.     This  anomaly  is  also  known  as  a  uterus  septus  hilocularis. 


Fig.  is. — Double  Uterus.     {From  Byford,  after  OlUvier.) 

a.  Right  cavity,  b.  Left  cavity,  c.  Right  ovary,  _  d.  Right  round  ligament,  _  e 
Left  round  ligament,  f.  Left  tube.  g.  Left  vaginal  portion,  h.  Right  vaginal 
portion,     i.  Right  vagina,     j.  Left  vagina,     k.  Portion  between  two  vaginae. 

Where  two  uterine  cavities  exist  with  but  a  single  cervix,  it  is  de- 
scribed as  uterus  semi-partitus.  Occasionally  the  whole  genital  tract 
is  double,  the  septum  extending  to  the  vulva,  so  that  there  are  two 
vaginas. 

Sometimes  a  single  cornu  of  the  uterus  is  developed  to  such  an 
extent  as  to  be  capable  of  containing  a  fetus  during  gestation.  This 
condition  is  known  as  a  uterus  unicornis. 


26  COMPEND    OF    OBSTETRICS 

What  is  a  uterus  bicornis? 

It  is  a  two-horned  uterus,  and  is  caused  by  an  incomplete  fusion  of 
Muller's  ducts. 

What  is  a  uterus  duplex? 

It  is  two  distinct  uteri,  and  is  caused  by  a  lack  of  union  between 
Muller's  ducts  throughout  their  entire  length. 

What  is  a  uterus  cordiformis? 

This  is  a  heart-shaped  uterus,  its  peculiarity  of  form  being  caused 
by  an  incomplete  development  of  the  fundus. 


Fig.  i6. — Rudimentary  Sexual  Organs. — (Luschka.)  The  internal  organs  repre- 
sented at  the  seventh  week  of  fetal  life;  the  external  organs  belong  to  a  later 
period. 

I.  Spinal  column.  3,3.  Wolffian  bodies.  5.  Glands  destined  to  become  the  ovaries 
in  the  females,  the  testicles  in  the  male.  6.  Wolffian  duct,  7,  Filaments  of 
Mullen  8.  Bladder.  9.  Tubercle,  forming  the  rudiment  of  either  the  clitoris 
or  penis.  10.  Folds  destined  to  form  the  albia  majora  (in  the  male  the  scrtoum). 
II.  Sinus  uro-genitalis.     12.  Anus. 

What  is  the  cause  of  all  anomalies  of  uterine  development? 

Arrest  of  development  of  the  embryo. 

What  are  the  Fallopian  tubes,  or  oviducts? 

The  Fallopian  tubes,  or  oviducts,  are  small  tubes  which  extend 
from  each  cornu  of  the  uterus.  They  are  formed  from  the  upper 
ununited  parts  of  Muller's  ducts. 

What  is  their  structure? 

They  are  continuous  in  structure  with  the  uterus,  being  mainly 
muscular,  covered  with  peritoneum,  and  lined  with  a  single  layer 


THE    REPRODUCTIVE    ORGANS  27 

of  ciliated  columnar  epithelium,  whose  wave-like  motion  is  toward 
the  uterine  cavity.  The  mucous  membrane  is  thrown  into  deep 
longitudinal  folds,  which  become  more  complex  as  the  fimbriated 
extremity  is  approached.  There  are  no  glands  in  the  mucous  mem- 
brane. The  average  caliber  is  one-sixteenth  of  an  inch,  and  their 
length  about  5  inches.  For  convenience  in  description  the  tube 
is  divided  into  the  uterine  portion,  isthmus,  ampulla  infundibulum. 

The  uterine  portion  extends  from  the  cornea  (including  the  por- 
tion within  the  uterine  wall)  to  the  upper  angle  of  the  uterine  cavity. 
The  isthmus  is  the  narrowest  portion  immediately  adjoining  the 
uterus.  It  gradually  passes  into  the  wider  lateral  portion  or  am- 
pulla. The  infundibulum  or  fimbriated  extremity  is  the  funnel-shaped 
opening  of  the  lateral  end  of  the  tube.  It  is  the  outer  external  end 
or  that  next  the  ovary. 

The  ovaries  are  two  flattened  almond-shaped  organs  whose  prin- 
cipal function  is  the  development  and  extension  of  ovules.  Their 
average  length  during  the  child-bearing  period  is  about  2.5  to  5  centi- 
meters in  length  1.5  to  3  centimeters  in  breadth  and  0.6  to  1.5  centi- 
meters in  thickness  (Williams).  They  vary  considerably  according 
to  the  age  of  the  female  and  after  the  menopause  markedly  decrease 
in  size. 

What  is  the  position  of  the  ovaries? 

The  ovaries  are  normally  situated  in  the  upper  part  of  the  pelvic 
cavity,  one  surface  of  each  ovary  resting  in  a  slight  depression  in  the 
upper  portion  of  the  inner  surface  of  the  obturator  muscle,  the  fossa 
ovarica.  With  the  woman  standing,  the  long  axis  of  the  ovaries 
occupy  a  nearly  vertical  position.  When  the  woman  is  in  the  hori- 
zontal position  on  her  back  their  position  is  nearly  horizontal.  They 
may  vary  somewhat  in  position.  Each  ovary  presents  for  examination 
two  surfaces,  two  margins,  and  two  poles.  The  surface  which  is  in 
contact  with  the  ovarian  fossa  is  called  the  lateral,  while  the  one 
directed  toward  the  uterus  is  known  as  the  median  surface.  The 
margin  which  is  attached  to  the  mesovarian  is  more  or  less  straight  and 
is  designated  the  hilum,  while  the  free  margin  is  markedly  convex 
and^  is  directed  backward  and  inward  toward  the  rectum.  The 
extremities  of  the  ovary  are  termed,  the  upper  and  lower  or  tubal  and 
uterine  poles  respectively.  In  young  women  the  ovary  presents  a 
smooth,  dull  white  appearance  through  which  glistens  a  number 
of  small  semi-transparent  vesicles  the  Graafian  follicles.  In  age  the 
ovaries  takes  on  a  corrugated  appearance. 


28  COMPEND    OF    OBSTETRICS 

What  are  the  attachments  of  the  ovary? 

The  ovary  is  attached  to  the  broad  Hgament  by  the  mesovarian 
which  forms  the  posterior  leaf  of  that  structure.  The  ovarian 
ligament  extends  from  the  lateral  and  posterior  portions  of  the  uterus, 
just  beneath  the  tubal  insertion,  to  the  uterine  or  lower  pole  of  the 
ovary.  It  is  several  centimeters  long  and  about  3  to  4  millimeters 
wide.  It  is  covered  by  peritoneum  and  is  composed  of  muscular  and 
connective-tissue  fibers  which  are  continuous  with  those  of  the 
uterus.  The  infundihiilo  pelvic  ligament  or"  suspensory  ligament  ex- 
tends from  the  upper  or  tubal  pole  of  the  ovary  to  the  pelvic  wall. 
It  represents  the  portion  of  the  upper  margin  of  the  broad  ligament 
which  is  not  occupied  by  the  tube  and  through  it  the  ovarian  vessels 
gain  access  to  the  broad  ligament. 

For  the  most  part,  the  ovary  projects  freely  in  the  abdominal  cav- 
ity and  is  not  covered  by  peritoneum  except  near  its  hilum. 

What  is  the  structure  of  the  ovary? 

The  structure  of  the  ovary  is  composed  of  two  portions:  The 
cortex  (zona  parenchymatosa)  and  medulla  (zona  vasculosa).  The 
cortex  or  outer  layer  varies  in  thickness  according  to  the  age  of  the 
individual  becoming  thinner  with  advancing  years.  It  is  in  the  cortex 
that  the  Graafian  follicles  are  situated.  The  cortex  is  composed 
of  spindle-shaped  connective-tissue  cells,  through  which  are  scattered 
primordial  and  Grafhan  follicles  in  various  stages  of  development 
which  become  less  numerous  with  the  age  of  the  woman.  The 
most  external  portion  of  the  cortex  presents  a  dull  white  appearance 
and  is  designated  the  Alhuginea.  It  is  not  analogous  with  the 
tunica  albuginea  of  the  testicle.  On  its  surface  is  a  single  layer  of 
cuboidal  epithelium.     The  ovarian  epithelium  of  Waldeyer. 

The  Medulla  or  central  portion  of  the  ovary  (zona  vasculosa)  is 
composed  of  loose  connective  tissue  which  is  continuous  with  that 
of  the  misovarian.  It  contains  a  large  number  of  blood-vessels  and 
a  number  of  non-striated  muscle  fibers.  It  is  by  some  classified  as 
erectile  tissue. 

In  the  neighborhood  of  the  hilum  occasionally  may  be  observed 
short  ducts  or  tubes  which  are  lined  by  a  single  layer  of  columnar 
epithelium.     Their  significance  is  obscure. 

In  the  human  fetus  collections  of  epithelial  cells  are  sometimes 
observed  near  the  hilium.  These  are  arranged  in  masses  or  strands 
sharply  marked  off  from  the  surrounding  stroma.  These  are  the 
medullary  cords  of  Kollicker. 


THE    REPRODUCTIVE    ORGANS  29 

The  nerve  supply  of  the  ovary  is  derived  chiefly  for  the  sympathetic 
plexus  while  a  few  fibers  are  derived  from  the  plexus  surrounding  the 
ovarian  branch  of  the  uterine  artery. 

The  arterial  supply  of  the  ovaries  is  from  the  ovarian  arteries. 

The  return  flow  of  blood  for  the  ovaries  is  through  the  ovarian 
veins  forming  later  the  pampiniform  plexus  which  terminate  as  follows : 
the  right  emptying  into  the  inferior  vena  cava,  the  left  into  the  renal 
veins.  The  ovaries  are  generally  believed  to  secrete  or  elaborate  a 
secretion  of  their  own  and  may  be  thus  classed  among  the  ductless 
glands.  This  secretion  appears  to  have  some  important  effect  on  the 
general  economy  of  the  female. 

What  are  accessary  ovaries? 

These  are  small  accessary  bodies  occasionaly  found  on  the  broad 
ligament  in  the  neighborhood  of  the  main  ovary.  They  are  usually 
small  but  may  occasionally  attain  considerable  size.  They  may 
result  from  faulty  development  but  they  are  said  more  frequently  to 
result  from  inflammatory  changes  during  fetal  life;  small  portions  of 
the  real  ovary  becoming  cut  off  from  the  main  body  of  the  organ. 

"What  is  the  parovarium? 

The  parovarium,  or  organ  of  Rosenmuller,  consists  of  several 
tubes  placed  between  the  folds  of  the  broad  ligament.  There  is 
one  on  each  side  of  the  uterus.  They  are  supposed  to  be  the  remains 
of  the  Wolffian  bodies,  and  have  no  known  function.  They  are 
analogous  to  the  epididymis  of  the  male.  Very  large  cysts  are  some- 
times developed  from  them. 

What  is  the  vagina? 

A  musculomembranous  tube  which  serves  to  connect  the  uterus 
and  its  appendages  with  the  outside  of  the  body.  It  is  attached  above 
to  the  uterus  and  terminates  below  in  the  vulva.  It  is  situated 
behind  the  urethra  and  bladder  from  which  it  is  separated  by  the 
vesjco- vaginal  sepium.  Posteriorly  between  its  lower  portion  and 
the  rectum  we  have  the  perineum  and  recto-vaginal  septum.  Its 
median  portion  lies  in  close  opposition  with  the  rectum,  while  its 
upper  portion  is  separated  from  it  by  Douglas  cul-de-sac. 

How  is  the  vagina  attached  to  the  uterus? 

It  is  inserted  upon  the  outside  of  the  womb,  at  the  junction  of 
the  body  and  neck,  so  that  the  neck  of  the  uterus  projects  into 
the  tube  at  right  angles  when  the  uterus  is  in  normal  position. 


30  COMPEND    OF    OBSTETRICS 

What  is  the  structure  of  the  vagina? 

It  is  composed  of  fibrous  connective  tissue  and  of  muscular  fibers, 
for  the  most  part  circularly  arranged.  The  external  coat  is  con- 
tinuous with  the  ordinary  cellular  tissue  or  packing  of  'the  pelvis. 
The  middle  or  muscular  coat  is  composed  of  two  layers  of  fibers, 
longitudinal  and  transverse.  The  muscular  tissue  is  chiefly  of  the 
unstriped  or  involuntary  variety.  Within,  it  is  lined  with  mucous 
membrane,  which  is  reflected  over  the  cervix  uteri  above,  and  below 
is  continuous  with  the  mucous  membrane  of  the  vulva. 

^    How  does  the  mucous  membrane  of  the  vagina  differ  from  that 
of  the  uterus? 

It  is  composed  simply  of  flat  or  pavement  epithelial  cells,  and 
has  only  a  few  glands.  Numerous  depressions  or  crypts  in  the 
membrane  answer  a  similar  purpose  and  secrete  a  mucus  of  acid 
reaction.  In  the  virgin  it  is  disposed  in  many  transverse  ridges, 
called  rugag. 

How  long  is  the  vagina? 

Its  anterior  wall  is  quite  short,  extending  from  the  vulva  almost 
directly  to  its  point  of  insertion,  a  small  pouch  being  formed  above, 
called  the  anterior  vaginal  pouch,  fornix  or  cul-de-sac.  The  posterior 
wall  is  longer,  being  prolonged  upward  to  form  a  larger  pouch 
behind  the  uterine  neck,  called  the  posterior  vaginal  or  retro-uterine 
pouch,  fornix  or  cul-de-sac.  The  lateral  insertion  of  the  vagina  with 
the  cervix  form  the  lateral  f ornices  or  cul-de-sacs.  The  average  length 
of  the  vagina  is  from  3  to  5  inches,  varying  in  individuals  and  in 
races,  21/2  inches  for  the  anterior  and  a  little  over  3  inches  for  the 
posterior  wall  (Lusk). 

What  is  the  blood  supply  of  the  vagina? 

Its  upper  third  is  supplied  by  the  cervico-vaginal  branches  of  the 
uterine  arteries.  Its  middle  third  by  the  inferior  vesical  arteries. 
Its  lower  third  by  the  medium  hemorrhoidal  and  internal  pudic 
arteries. 

The  veins  surround  the  vagina  in  an  abundant  plexus  following  the 
course  of  the  arteries  and  eventually  empty  into  the  hypogastric 
veins. 

The  lymphatics  from  the  lower  third  of  the  vagina  empty  into  the 
vaginal  lymph  glands.  Those  of  the  middle  third  into  the  hypogastric 
and  those  of  the  upper  third  into  the  iliac  glands. 


THE    REPRODUCTIVE    ORGANS 


31 


The  nerve  supply  of  the  vagina  is  derived  from  the  hypogastric 
plexus  and  fourth  and  fifth  sacral  nerves. 

Where  is  Douglas'  cul-de-sac? 

It  is  situated  in  the  abominal  cavity,  directly  behind  the  poste- 
rior vaginal  pouch  or  fornix,  and  therefore  between  the  vagina  and 
rectum.     It  is   a  -very  important   space,   because,   being   the   most 


Fig.  17. — Hymen  Annularis. — {Montgomery.) 

dependent  portion  of  the  abdominal  cavity,   effusions  of  blood  or 
other  fluid  and  tumors  of  various  kinds  are  often  to  be  found  in  it. 

How  does  the  vagina  terminate  below? 

It  terminates  in  a  circular  fold  of  mucous  membrane  called  the 
hymen.  From  the  fact  that  this  fold  is  often  more  developed  in 
its  posterior  half,  it  usually  appears  as  a  crescentic  fold,  stretching 
across  the  opening  of  the  vagina  (see  8,  Fig.  i). 


32 


COMPEND    OF    OBSTETRICS 


What  is  an  imperforate  hymen? 

The  membrane  sometimes  completely  closes  the  opening  of  the 
vagina,  and  is  then  said  to  be  imperforate. 

What  is  the  structure  of  the  hymen? 

It  is  composed  almost  entirely  of  mucous  membrane,  and  is 
easily  torn  by  the  entrance  of  the  male  organ,  but  is  sometimes 
firm  -enough  to  resist  any  ordinary  pressure,  and  may  cause  delay 
in  labor  by  its  presence.     It  may  be  absent  at  birth.     While  laceration 


Fig.   i8. — Hymen  Serratus.— {Montgomery.) 


or  absence  of  the  hymen  is  supposed  to  be  a  mark  of  the  lack  of 
virginity  such  is  not  always  the  case.  It  may  be  lacerated  by 
accident  or  by  gynecological  examinations.  It  is  usually  present, 
however,  in  a  virgin.  Various  differences  in  the  shape  and  appear- 
ance of  the  hymen  are  to  be  noted  as  the  hymen  fimbriatum, 
hymen  annularis,   hymen    cribriformis.    When  the    hymen  extends 


/ 


THE    REPRODUCTIVE    ORGANS 


33 


completely  across  the  vaginal  opening  it  is  known  as  an  imperforate 
hymen. 

What  are  the  carunculae  myrtiformes? 

When  the  hymen  is  torn  and  greatly  stretched,  as  by  the  passage 
of  a  child's  head,  or  a  large  fibroid  tumor,  its  fragments  undergo 
atrophy,  and  there  remain  little,  wart-like  elevations  in  the  line  of  the 
hymen,  called  carunculae  myrtiformes.     It  is  said,  however,  that  these 


Fig.   19. — Hymen  Cribriformis. — {Montgomery.) 

bodies  sometimes  coexist  with  the  hymen,  being  placed  a  little  distance 
behind  it. 

What  are  the  bulbs  of  the  vagina? 

They  are  masses  of  erectile  tissue,  mainly  composed  of  short,  venous 
sinuses,  shaped  somewhat  like  a  pair  of  saddle  bags,  and  placed  over 
and  at  the  side  of  the  vagina.  They  are  supposed  to  correspond  to  the 
two  halves  of  the  male  bulbus  urethrse. 


34 


COMPEND    OF    OBSTETRICS 


What  are  the  vulvo -vaginal  glands? 

The  vulvo-vaginal  glands,  or  glands  of  Bartholin,  are  two  small 
bodies  situated  just  behind  the  hymen,  one  on  either  side.  They  are 
embedded  in  the  cellular  tissue  around  the  vagina,  and  empty  by  a 
small  duct  on  either  side.  They  secrete  a  thin  mucus,  which  is 
expelled  freely,  and  even  by  jets,  during  venereal  excitement  and 
coitus. 

THE  EXTERNAL  ORGANS,  OR  PUDENDA* 

See  Fig.  i 

Describe  the  development  of  the  external  sexual  organs? 

Prior  to  the  sixth  week  the  external  openings  of  the  gut  and  of 
the  urinary  tract  are  received  into  a  common  tube,  the  cloaca,  whose 
recto-uro-genital  orifice  is  surmounted  by  a  small  conical  elevation, 
the  genital  tubercle.  The  lower  and  posterior  surface  of  this  tubercle  is 
divided  by  a  furrow,  the  genital  groove  bounded  by  thickened  lips,  the 


Fig.  20. — Formation  OF      Fig.     21. —  Cloaca 


Perineum  and  Ure- 
thra.— {From  Byford, 
after  Schroeder.) 
Su.  By  descent  of  per- 
ineal tissue.  M.  Ure- 
thra. 


Formed  with  De- 
scent  OF   THE    Tis- 

SXJE     between     THE 

Rectum  and  the 
Allantois.  —  {By- 
ford,  after  Schroeder.) 

V.  Vagina.  R.  Rec- 
tum. B.  Bladder. 
CI.  Cloaca. 


Fig.  22. — Fully  Formed 
Genitals. — {From  Byford, 
after  Schroeder.) 

The  urogenital  sinus  forms 
the  vestibule  separated 
from  the  vagina  by  the 
hymen.  Su.  By  descent 
perineal  tissue,  u.  Ure- 
thra. 


genital  folds.  Outside  the  latter  a  smaller  fold  constitutes  the  genital 
ridges.  The  end  of  the  genital  tubercle  enlarges  and  becomes  bulbous, 
forming  the  primitive  glans  of  the  future  penis  or  clitoris.  Toward 
the  end  of  the  second  month  the  imperfectly  formed  septum  between 
the  rectum  and  the  urino-genital  passage  reaches  perfection,  whereby 
the  complete  separation  between  the  alimentary  and  genito-urinary 
canals  is  effected.  In  the  male  the  genital  tubercle  elongates  to  form 
the  penis;  while  the  genital  furrow  on  its  under  surface  unites  to 
form  the  penile  portion  of  the  urethra.  Coincidently,  the  closure  of 
the  edges  of  the  urino-genital  passages  takes  place,  the  tube  thus 


THE   REPRODUCTIVE    ORGANS  35 

formed  becoming  continuous  with  the  anterior  part  of  the  urethra. 
The  primitive  genital  ridges  or  outer  genital  folds  unite  to  form  the 
scrotum.  In  the  female  the  genital  tubercle  remains  small  and  be- 
comes the  -clitoris,  the  genital  furrow  remains  open,  thus  forming  the 
lesser  labia,  while  the  external  folds  form  the  greater  labia. 

What  is  the  eax^liest  period  of  intra-uterine  life  at  which  the  sex  of 
the  embryo  can  be  recognized? 

The  sexual  characteristics  are  well  developed  by  the  third  month. 

What  is  the  vulva? 

The  name  given  to  the  external  organs  collectively,  but  often  used 
to  denote  the  genital  fissure  or  vulval  canal. 

What  are  the  labia  majora? 

Elevated  folds  of  cutaneous  "tissue,  which  are  found  on  either  side 
of  the  genital  fissure. 

What  is  the  structure  of  the  labia  majora? 

They  consist  of  cutaneous  folds  containing  loosely  arranged  cel- 
lular tissue,  with  some  fat.  On  the  outer  surface  they  are  covered  by 
a  free  growth  of  stout  curly  hair,  similar  to  that  found  in  the  axilla. 
On  their  inner  surface  they  are  furnished  with  a  considerable  number  of 
sebaceous  follicles. 

What  is  the  mens  veneris? 

An  eminence  of  cutaneous  tissue,  the  anterior  termination  of  the 
labia  majora,  situated  directly  upon  the  symphysis  pubis.  It  is  well 
padded  with  fat  and  covered  with  an  abundance  of  hair. 

What  is  the  anterior  commissure? 

The  point  just  under  the  mons,  where  the  labia  meet  in  front.  The 
anterior  limit  of  the  genital  fissure. 

What  is  the  posterior  commissure? 

The  posterior  Hmit  of  the  genital  fissure,  or  the  point  where  the 
labia  meet  posteriorly.  It  marks  the  anterior  boundary  of  the 
perineum. 

What  is  the  fourchette? 

When  the  genital  fissure  is  made  to  gape  by  the  fingers  pulling 
apart  the  labia  majora,  a  fold  of  mucous  membrane  is  made  to 
project  behind  the  posterior  commissure,  which  is  called  the  fourchette. 


36  COMPEND    OF    OBSTETRICS 

The  little  dimple  or  cup  between  this  fold  and  the  commissure  is 
called  the  fossa  navicularis,  but  neither  of  them  have  any  existence 
until  artificially  produced  in  this  manner. 

What  is  the  clitoris? 

A  small,  cylindrical  body,  about  an  inch  in  length,  which  resembles 
and  is  the  analogue  of  the  male  penis.  It  consists  of  two  corpora 
cavernosa,  which  are  attached  to  the  under  edge  of  the  pubic  bone, 
and  by  their  free  end  project  slightly  under  the  anterior  commissure. 
The  part  which  is  visible  is  about  the  size  of  a  pea. 

What  are  the  labia  minora? 

Called  also  the  NymphcR.  They  are  two  folds  of  dartoid  tissue, 
covered  by  skin,  which  cover  the  clitoris  in  a  manner  similar  to  the 
prepuce  of  the  penis,  and  extend  backward  along  the  sides  of  the 
labia  majora  for  about  one-half  their  extent. 

What  is  their  structure? 

It  nearly  resembles  that  of  the  male  scrotum,  inclosing  also  some 
erectile  tissue. 

What  is  the  vestibule? 

The  space  which  extends  from  the  clitoris  to  the  opening  of  the 
vagina,  and  is  bounded  laterally  by  the  labia  minora. 

What  and  where  is  the  meatus  urinarius? 

It  is  the  opening  of  the  urethra,  and  is  placed  at  the  posterior  limit 
of  the  vestibule,  and  therefore  just  above  the  opening  of  the  vagina. 
It  is  situated  in  a  tubercle  or  slight  eminence. 

How  long  is  the  female  urethra? 

About  one  and  one-half  inches. 

How  is  the  urethra  situated  with  respect  to  the  vagina? 

It  lies  directly  over  it,  and  can  be  distinctly  recognized,  by  the 
finger  introduced  into  the  vagina,  as  a  tubular  ridge  above  the  anterior 
wall  of  the  vagina. 

What  is  the  perineum? 

The  space  between  the  vulva  and  anus,  and  bounded  laterally  by 
the  tuberosities  of  the  ischia. 

How  is  the  pelvic  floor  divided  in  its  relation  to  labor? 

Into  two  segments:  a  pubic  and  a  sacral  segment.  The  anterior  or 
bupic  segment  is  composed  of  loose  tissue  attached  in  front  to  the 


OVULATION  37 

symphysis  pubis.  It  contains  the  bladder,  urethra,  anterior  vesical 
wall,  and  the  bladder  peritoneum.  The  sacral  or  posterior  segment 
is  attached  to  the  sacrum  and  coccyx.  It  consists  of  the  rectum, 
perineum,  and  strong  tendinous  and  muscular  tissue. 

What  effect  has  labor  on  these  segments? 

During  labor  the  uterine  contractions  draw  up  the  pubic  or  anterior 
segment,  while  the  posterior  or  sacral  segment  is  pushed  down  by  the 
presenting  part. 

What  is  the  perineal  body? 

It  consists  of  a  wedge-shaped  band  of  fibrous  elastic  tissue,  which 
stretches  across  from  one  ischial  tuberosity  to  the  other,  and  is 
interposed  between  the  termination  of  the  vagina  and  rectum. 

What  other  structures  of  importance  are  found  in  the  perineum? 

The  transversus  perinaei  and  levator  ani  muscles,  and  also  fibers  of 
the  sphincter  muscles,  which  are  placed  about  the  ends  of  the  vagina 
and  rectum. 

PHYSIOLOGY 
OVULATION 

What  is  the  function  of  the  ovaries? 

To  furnish  ova,  or  eggs,  which  are  the  primitive  germs  of  the 
human  being,  and  the  necessary  female  element  in  reproduction. 

What  is  the  function  called? 

Ovulation. 

How  early  in  life  does  ovulation  begin? 

In  childhood.  (Sinedy  and  Hausmann  found  evidence  of  ovulation 
in  10  per  cent,  of  infants  examined  by  them.)  But  it  does  not  occur 
with  much  vigor  until  womanhood. 

Where  are  the  ova  found? 

In  small  cystic  bodies  called  ovisacs,  or  Graafian  vesicles  (or 
follicles),  there  being  usually  but  one  ovum  in  each  ovisac. 

How  many  ovisacs  exist  in  each  ovary? 

There  are  variously  estimated  from  30,000  to  650,000  ovisacs  or 
oocytes,  but  only  a  score  or  so  can  be  observed  at  any  one  time.  A 
very  large  number  are  said  to  disappear  before  puberty. 


3^ 


COMPEND    OF    OBSTETRICS 


Describe  the  ovum  when  fully  developed. 

The  ovum,  when  fully  developed,  is  a  spherical  mass  of  proto- 
plasm, 1/120  of  an  inch  in  diameter.  It  is  structureless,  except  that 
it  contains  at  one  point  a  small  body  like  a  nucleus,  called  the  germinal 
vesicle,  which  in  turn  contains  a  smaller  body,  Hke  a  nucleolus,  called 
the  germinal  spot.  The  ovum  is  surrounded  by  a  thin  envelope  of 
albuminous  matter,  called  the  zona  pellucida,  or  vitelline  membrane, 
but  which  is  not  a  distinct  membrane  until  after  impregnation,  the 
ovum  itself  being  called,  also,  the  vitellus  or  yolk. 

Describe  the  process  of  ovulation. 

The  ovisac,  at  first  very  minute,  is  embedded  in  the  cortical  layer 
of  the  ovary.  Its  wall  consists  of  a  layer  of  cells,  called  the  membrana 
propria,  within  which  is  found  a  second  layer,  the  membrana  granu- 


FiG.  23. — 0.  Ovarian  tissue.  Y.  Yolk.  z.p.  Zona  pellucida  or  vitelline  membrane. 
G.  V.  Germinal  vesicle.  G.  s.  Germinal  spot.  D.  p.  Discus  proligerus.  M.  G. 
Membrana  granulosa.     M.  p.    Membrana  propria. 


losa.  An  accumulation  of  these  cells  form  a  little  mound,  called 
the  proligerous  disk,  and  in  this  the  ovum  is  situated.  These  cells 
secrete  within  the  ovisac  an  albuminous  fluid.  While  the  ovisac 
increases  in  size,  it  also  approaches  the  surface  of  the  ovary,  having 
then  attained  a  diameter  of  one-fourth  to  one-half  of  an  inch.  At 
this  point  is  stops  growing,  while  the  fluid  continues  to  be  secreted 
in  its  interior.  This  finally  subjects  the  ovisac  and  the  overlying 
covering  of  the  ovary  to  a  bursting  pressure;  the  ovisac  is  ruptured, 
and  the  ovum,  with  some  of  the  fluid  and  epithelium  of  the  ovisac,  is 
extruded  upon  the  surface  of  the  ovary. 


OVULATION  39 

What  happens  to  the  ovisac  after  the  discharge  of  the  ovum? 

Several  things  may  occur: 

1.  The  entire  contents  of  the  ovisac  may  be  extruded,  the  walls 
collapse,  and  within  a  week  or  two  a  small  linear  cicatrix  only 
is  left  to  show  that  ovulation  has  occurred. 

2.  Some  blood  may  be  effused  into  the  sac  at  the  time  of  rupture. 
A  clot  is  formed,  which  is  slowly  absorbed;  as  its  hematin  becomes 
faded  and  yellowish,  it  is  called  the  corpus  luteum. 

3.  Should  the  woman  become  pregnant,  the  walls  of  the  ovisac 
may  continue  to  secrete  fluid.  This  is  due  to  the  increased  blood 
supply  which  pregnancy  occasions;  and  this  leads  to  the  forma- 
tion of  a  large,  yellowish  body,  called  the  corpus  luteum  of  pregnancy. 

What  coverings  has  the  ovum  when  it  escapes  from  the  ovisac? 

It  is  covered  externally  by  a  layer  of  cells  from  the  membrana 
granulosa,  called  the  discus  proligerus,  internally  by  a  thick  trans- 
parent membrane  termed  the  vitelline  membrane,  or,  from  the 
way  in  which  it  transmits  light,  it  is  called  the  zona  pellucida.  The 
ovurn  and  zona  pellucida  are  not,  however,  in  immediate  contact, 
for  between  them  there  is  found  a  space,  termed  the  perivitelline 
space,  which  permits  ameboid  movement  of  the  protoplasm  of  the 
egg. 

What  happens  to  the  ovum  after  its  escape  from  the  ovisac? 

1.  It  may  drop  into  the  abdominal  cavity  and  perish. 

2.  It  is  wafted  toward  the  open  end  of  the  Fallopian  tube  by  means 
of  a  current  in  the  fluid  bathing  the  tissues,  which  current  is  caused 
by  the  action  of  ciliated  epithelial  cells,  and  is  always  directed 
toward  the  tube. 

3.  The  end  of  the  tube  may,  by  a  spasmodic  movement,  clasp  the 
surface  of  the  ovary  and  draw  the  ovum  into  the  tube. 

4.  When  in  the  tube  it  is  passed  on  to  the  womb  {a)  by  a  ciliary 
current,  and  {h)  possibly  by  peristalsis,  and  from  the  womb  it 
is  discharged  with  the  mucus,  etc.,  unless  fecundated. 

5.  It  may  become  fecundated  and  remain  within  the  mother  until 
developed  into  a  child. 

How  often  does  ovulation  take  place? 

It  is  irregular  in  its  occurrence.  A  number  of  ovisacs  are  con- 
stantly being  developed,  with  greater  or  less  rapidity,  and  the  amount 
of  the  blood  supply  of  the  ovary  controls  the  rate  of  development. 
Frequent  coitus  leads  to  frequent  ovulation  for  this  reason. 


40  COMPEND    OF    OBSTETRICS 

What  is  the  usual  interval  between  the  discharge  of  successive 
ova? 

Usually  once  a  month,  because  the  greatest  increase  in  the  blood 
supply  occurs  once  a  month,  during  menstruation. 

MENSTRUATION 

What  is  menstruation? 

A  periodical  disturbance  in  the  female,  characterized  by — ■ 

1.  An  increase  in  the  vascular  tension  throughout  the  body, 

2.  A  special  determination  of  blood  to  the  pelvic  organs  (or  pelvic 
hyperemia). 

3.  A  renovation  of  the  uterine  mucous  membrane. 

4.  A  discharge  of  blood  mixed  with  mucus  from  the  uterus. 

How  often  does  menstruation  occur? 

Once  every  twenty-eight  days;  but  the  interval  varies  in  some 
women  from  three  to  six  weeks. 

What  is  the  first  evidence  of  menstruation? 

An  increase  in  the  vascular  tension  and  a  sense  of  fulness  in  the 
pelvic  region,  which  may  be  accompanied  by  pain. 

What  effect  has  the  pelvic  hyperemia  on  the  ovaries? 

By  increasing  the  blood  supply  it  hastens  the  development  of 
the  ovisacs,  and  one  or  more  usually  rupture  at  this  time. 

What  effect  has  the  pelvic  hyperemia  on  the  uterus? 

The  uterus  becomes  larger  and  softer,  and  its  mucous  membrane 
undergoes  changes  as  follows:  i.  New  cells  are  formed.  2.  The 
outer  layer  or  layers  of  epithelium  are  thrown  off.  3.  The  mem- 
brane is  turgid  with  blood  and  thrown  into  folds.  4.  There  is  in- 
creased functional  activity  in  the  mucous  follicles,  and  a  more  abun- 
dant secretion  of  mucus.  5.  Some  of  the  superficial  capillaries  break 
down,  and  an  oozing  of  blood  takes  place. 

What  is  the  clinical  course  of  menstruation? 

1 .  The  woman  notices  a  leucorrhea  for  one  or  two  days. 

2.  A  discharge  of  blood  for  three  days  (average). 

3.  A  continuance  of  leucorrhea  for  one  or  two  days. 


MENSTRUATION  4I 

Is  menstruation  attended  with  pain? 

Not  normally,  but  the  majority  of  women  experience  some  degree 
of  pelvic  pain,  because  the  parts  are  hypersensitive,  from  some 
departure  from  the  normal  condition.  The  pain  is  usually  referred  to 
the  "small  of  the  back";  also  to  the  ovarian  regions  and  to  the  hypo- 
gastrium.  There  may  also  be  present  sensations  of  rapid  changes  of 
temperature,  chilliness,  or  heat;  the  bladder  may  be  quite  irritable,  and 
diarrhea  may  appear.  Some  women  suffer  from  severe  headaches 
and  may  become  quite  hysterical  at  these  times.  There  may  also  be 
a  sense  of  fullness  and  tingling  in  the  breasts. 

What  peculiarities  has  the  menstrual  blood?  , 

1.  It  is  blood  mixed  with  epithelial  cells. 

2.  It  does  not  coagulate  when  moderate  in  amount,  because  it  is  made 
acid  by  the  vaginal  mucus. 

How  much  blood  is  discharged  during  menstruation? 

From  Bss  to  giij  in  all;  but  the  amount  varies. 

Is  the  blood  during  menstruation  always  discharged  from  the 
uterus? 

No.  The  uterine  mucous  membrane  sometimes  fails  to  undergo  its 
usual  changes,  and  weakened  capillaries  in  any  part  of  the  body  may 
break  down  under  the  increased  vascular  tension.  Thus  we  may  have 
menstrual  hemorrhage  from  the  stomach,  lungs,  breasts,  or  any 
part  whatever. 

What  is  this  condition  called? 

Vicarious  menstruation,  or  xenomenia. 

What  is  meant  by  supplementary  menstruation? 

Supplementary  menstruation  is  a  hemorrhage  from  any  of  the 
mucous  membranes  of  the  body,  produced  by  the  congestion  incident 
to  menstruation  and  coexistent  with  the  usual  discharge  of  blood  from 
the  genitalia. 

What  are  the  popular  names  for  menstruation? 

To  be  unwell;  to  see  anything;  to  be  regular;  the  periods;  courses; 
sickness;  monthlies;  turns;  changes,  and  flowers. 

What  is  the  object  of  menstruation? 

To  insure  the  development  of  ova  by  a  periodical  increase  in  the 
ovarian  blood  supply,  and  to  favor  the  detention  of  the  ovum  in  the 
uterus  by  the  changes  in  the  mucous  membrane. 


42  COMPEND    OF    OBSTETRICS 

When  do  women  begin  to  menstruate? 

As  soon  as  they  become  women,  which  period  is  called  puberty. 

"When  does  puberty  begin? 

It  varies  from  race,  climate,  and  social  condition.  The  average  is 
at  the  age  of  fifteen  years. 

What  physical  signs  attend  the  age  of  puberty? 

The  reproductive  organs  are  fully  developed,  the  breasts  enlarge, 
the  pubes  is  covered  with  hair,  and  the  whole  form  of  the  girl  becomes 
rounded  and  womanly. 

What  is  nubility? 

It  is  the  period  of  life  most  suitable  for  reproduction. 

When  do  women  cease  to  menstruate? 

At  about  the  age  of  forty-five  years,  which  period  is  called  the 
menopause  or  climacteric,  or  "the  change  of  life." 

What  symptoms  usually  herald  the  approach  of  the  menopause? 

Menstruation  becomes  irregular  and  finally  ceases.  Sudden 
flushes  of  heat  and  cold,  and  hyperemias  of  the  cerebrum  or  of  other 
organs  of  the  body  may  appear.  Some  women  are  quite  ill  at  this 
time. 

What  happens  to  the  reproductive  organs  at  the  menopause? 

They  gradually  atrophy,  but  the  possibility  of  child-bearing  may 
continue  until  the  age  of  fifty -five  (P.  Barker). 

Does  the  capacity  for  child-bearing  cease  with  the  menopause? 

Usually  it  does;  but  as  ovulation  occasionally  outlasts  the  menstrual 
function,  impregnat^'on  may  in  some  cases  take  place  after  the 
menopause. 

Does  impregnation  ever  take  place  before  menstruation  begins? 

Ovulation  sometimes  precedes  menstruation,  and  consequently  such 
a  case  is  possible. 

What  is  the  main  function  of  the  uterus? 

To  receive  the  fecundated  ovum,  and  to  retain  it  until  it  is  developed 
into  a  mature  fetus. 

What  is  the  function  of  the  oviducts? 

To  convey  the  ova  to  the  uterus,  and  the  spermatozoa  to  the  ova. 


MENSTRUATION 


43 


What  is  the  function  of  the  vagina? 

It  serve's  as  a  duct  or  outlet  for  the  discharge  of  the  uterine  secre- 
tions, including  the  escape  of  the  child  in  labor,  and  also  to  admit  the 
male  organ,  so  that  the  semen  may  gain  access  to  the  ovum. 


Fig.  25. — Acinus  of 
M'AMMARY  Gland. 

What  is  the  function  of  the  ex- 
ternal organs? 

They  are  endowed  with  great 
sensibility,  and  are  mainly  con- 
cerned with  the  function  of  coitus. 
The  nymphae  also  serve  to  direct 
the  stream  of  urine  as  it  passes 
from  the  meatus  urinarius. 


Fig.  24. — I.  Galactophorous  duct. 
2.  Lobuli  of  the   mammary  glands. 


What    is    the    structure    of  the 
breast? 

The  breast  is  a  gland  of  the  racemose  variety,  and  is  composed  of 
fifteen  or  twenty  lobes  of  glandular  tissue,  with  a  packing  of  areolar  and 
adipose  tissue.  The  lobes  are  compounded  of  the  lobules  produced  by 
the  aggregation  of  the  terminal  acini,  in  which  the  milk  is  formed. 
The  ducts  of  each  lobule  unite  with  each  other  to  form  a  terminal  canal, 
called  the  galactophorous  duct,  of  which  there  is  one  for  each  lobe 
(Playfair).  These  empty  upon  the  face  or  extremity  of  the  cylin- 
drical appendage  called  the  nipple. 

What  is  the  areola? 

A  circular  patch  of  cutaneous  tissue  around  the  base  of  the  nipple, 
of  pink  color  in  virgins,  and  darker  in  those  who  have  borne  children 
and  in  brunettes.  It  contains  also  many  sebaceous  glands  in  ad- 
dition to  the  glands  or  tubercles  of  Montgomery  or  Morgagni. 
No  fat  is  found  beneath  the  skin  of  the  areola. 


44  COMPEND    OF    OBSTETRICS 

What  are  the  glands  of  Montgomery  or  Morgagni? 

Small  tubercle-like  projections  occupying  the  inner  circle  of  the 
areola.     They  enlarge  greatly  during  pregnancy. 

What  is  the  nipple? 

The  nipple  is  a  conical  projection  arising  from  the  center  of  the 
areola.     It  is  about  half  an  inch  in  height. 

Of  what  is  the  nipple  composed? 

Principally  of  the  terminals  of  the  galactophorus  ducts,  seba- 
ceous glands,  fat,  connective  tissue,  longitudinal  and  transverse 
muscular  fibers,  and  skin.  It  has  also  been  supposed  by  some  to 
contain  erectile  tissue. 

Affections  of  the  mammary  glands  will  be  treated  in  the  chapter 
on  "The  Period  After  Delivery." 

PREGNANCY 

What  is  pregnancy? 

The  condition  in  which  a  woman  contains  a  living  and  growing 
fetus. 

What  are  the  essential  requisites  for  the  occurrence  of  preg- 
nancy? 

1.  That  a  fully  matured  ovum  shall  be  recently  discharged  from 
the  ovary. 

2.  That  male  semen  shall  come  in  contact  with  such  an  ovum  before 
it  leaves  the  uterus. 

What  synonyms  are  given  for  this  act? 

Fecundation,  impregnation,  incarnation,  conception. 

What  is  fecundation? 

The  act  by  which  the  male  semen  imparts  to  the  ovum  the  power 
of  developing  into  a  fetus. 

What  part  of  the  semen  has  this  property? 

The  spermatozoa;  each  spermatozoon  resembles  a  ciliated  epi- 
thelial cell,  except  in  being  apparently  structureless  or  homogeneous. 
Each  drop  of  semen  contains  thousands,  all  of  which  are  in  constant 
vibratile  motion  during  life.  Their  length  is  about  1/500  to  1/600 
of  an  inch. 


Diagram  of  the  fetal  membranes  (structures  which  either  are,  or  have  been  at  an 
earlier  period  of  development,  continuous  with  each  other  are  represented  by 
the  same  color).  In  the  center  of  the  ovum  can  be  seen  the  embryo  itself.  The  dia- 
gram also  shows  the  manner  in  which  the  three  embryonic  layers  form  the  new 
being. 

Red,  Epiblast;  Blue,  Mesoblast;   Yellow,  Hypoblast. 


PREGNANCY 


45 


How  long  do  the  spermatozoa  retain  their  vitality? 

They  have  been  found  in  full  vigor  eight  days  after  their  intro- 
duction into  the  vagina. 

What  is  the  average  rate  of  motion  in  a  spermatozoon? 

About  an  inch  in  five  minutes  (Henle). 


m 


Fig.  26. — Head  and  Upper  Part  of  Spermatozoa. 
I.  Seen  from   above.     2.    Side  view. 


What  agents  lengthen  the  life  of  the  spermatozoon? 

Their  vitality  is  promoted  by  warmth,  a  slightly  alkaline  solu- 
tion, the  secretion  of  the  uterus.  It  would  seem  also  that  it  is 
possible  for  them  to  live  for  a  considerable  time  in  menstrual  blood. 

What  agents  destroy  the  life  of  the  spermatozoon? 

Injection  of  vinegar,  acids  generally,  strong  alkaline  solutions, 
and  bichlorid  of  mercury  in  a  strength  of  i  to  10,000  or  12,000; 
cold,  while  retarding  their  movements,  does  not  kill  them. 


46  COMPEND    OF    OBSTETRICS 

"When  is  sexual  intercourse  most  liable  to  be  followed  by  con- 
ception? 

During  the  week  following  the  cessation  of  the  menstrual  flow, 
the  probability  being  greatest  in  the  earlier  days  and  diminishing 
as  the  week  advances. 

Why  is  this  not  always  true? 

Because  a  woman  may  ovulate  any  time  between  the  menstrual 
period. 

How  and  where  is  contact  between  the  spermatozoa  and  ovum 
brought  about? 

1.  During  coitus  the  semen  is  ejected  against  the  cervix  uteri  and 
upper  part  of  the  vagina. 

2.  During  the  orgasm  of  the  female  the  uterus  sucks  or  pumps 
the  spermatozoa  into  its  cavity,  after  which  their  own  vibratile 
motion  causes  them  to  ascend  the  oviduct  until  they  meet  the 
ovum. 

3.  Fecundation  probably  occurs  most  frequently  in  the  oviduct, 
but  it  may  occur  at  any  point  between  the  ovary  and  the  os  uteri 
internum. 

Is  it  necessary  for  the  uterus  to  aid  the  entrance  of  the  -semen? 

No;  fecundation  has  occurred  when  the  woman  was  perfectly 
passive,  or  unconscious,  from  drugs,  drink  or  sleep. 

What  further  means  are  provided  for  the  retention  of  the  semen? 

1.  During  the  act  of  coition  the  round  ligaments  of  the  uterus  pull 
it  forward  and  upward.  This  permits  the  penis  to  glide  past 
the  cervix  and  to  deposit  the  semen  in  the  posterior  vagmal  pouch. 
When  the  ligaments  are  relaxed,  the  cervix  resumes  its  former 
position,  and  thus  retains  the  semen  in  the  pouch  above;  the 
spermatozoa  may  then,  at  their  leisure,  enter  the  uterus. 

2.  It  has  also  been  demonstrated  that  fecundation  can  take  place 
when  the  semen  escapes  upon  the  vulva,  so  that  the  whole  dis- 
tance may  be  traveled  by  the  spermatozoa  unaided. 

What  changes  take  place  in  the  ovum  after  fecundation? 

I.  When  the  ovum  is  mature,  two  small  cells  are  detached  from 
the  main  body  of  cells;  these  are  called  polar  globules.  It  was 
formerly  supposed  that  these  were  associated  with  the  disappear- 
ance of  the  germinal  vesicle,  but  recent  experiments  have  demon- 


PREGNANCY 


47 


strated  that  the  germinal  vesicle  plays  an  active  part  in  their 
formation.     This  can  take  place  independently  of  fecundation/^ 

2.  The  portion  of  the  ovum  remaining  after  the  throwing   off    of 
the  polar  globules  is  called  the  "female  pronucleus," 

3.  Fecundation  is  effected  by  the  penetration  of  the  head   of  one 
spermatozoon.     This  is  called  the  "male  pronucleus." 


-  li 

Fig.   27. — Segmentation  of  the  Vitellus. 


The  male  and  female  pronucleus  coalesce.  The  ovum  is  now 
called  the  oosperm,  or  blastophere. 

The  segmentation  of  the  nucleus  and  vitellus,  i.e.,  they  both 
split  into  two  masses,  these  into  four,  and  so  on  until  a  large 
number  of  segments  are  formed.  This  is  known  as  the  morula, 
moriform  body,  or  mulberry  mass  (see  Fig.  27), 


Fig. 


Fig. 


Section  of   Ovum. 


28. — The  Outer  Layer  of 

„,  •     -x-       ^  •        1  "  Shows    embryo    sinking    in    toward    the 

i  he  primitive  trace  m  the   center  of  the      center  of   the   ovum,    and  the   way   in 
area  germmativa.  which  the  ammonion  is  formed. 


6,  A  clear  fluid  is  secreted  within  the  ovum,  which  presses  these 
segments  to  the  surface  of  the  ovum,  where  they  form  a  double 
layer  of  cells,  differing  somewhat  in  size.  The  outer  and  larger 
is  termed  the  epiUast  or  ectoderm,  and  the  inner  and  smaller 
the' hypoblast  or  endoderm.  Together  they  are  known  as  the 
blastodermic  vesicle. 

7.  There  then  appears  upon  the  outside   of  the  vitellus,   a  small 
-      oval  elevation,  surrounded  by  a  depression,  which  is  called  the 

area  germinativa. 

4 


48 


COMPEND    OF    OBSTETRICS 


8.  There  appears  in  the  area  germinativa  a  small,  dark  line,  called 
the  primitive  trace.  About  this  line  will  be  grouped  the  various 
parts  of  the  embryo,  the  rest  of  the  ovum  serving  only  as  a  cover- 
ing and  for  nutriment  (see  Fig.  28). 

9.  A  covering  for  this  trace  or  embryo  is  now  formed.  Thus  far 
the  vitelline  membrane  has  been  sufficient.  The  embryonic  line 
sinks  into  the  center  of  the  ovum,  while  the  edges  of  the  exter- 
nal blastodermic  layer  about  the  area  close  around  it,  inclosing 
it  in  a  sac  called  the  amnion.  Between  the  amnion  and  the 
embryo,  fluid  at  a  later  period  is  deposited;  this  constitutes  the 
liquor  amnii  (see  Fig.  29).  The  vitelline  membrane  then  dis- 
appears. 

What  is  the  mesoblast? 

A  line  of  cells  developing  later  between  the  epiblast  and  hypoblast. 

What  are  formed  from  each  of  these  layers? 

I.  From  the  epiblast  (ectoderm),  the  epidermis,  hair,  nails,  the 
epithelium  of  the  mouth,  nose,  and  of  the  cloaca,  glands  of  the 
skin,  brain,  and  spinal  cord,  and  organs  of  special  sense. 


Fig.  30. — The  Amnion  Nearly 
Completed. 

The  allantois  carrying  blood-vessels  to 
the  circuroference  (a). 


CL- 


■Sk...l 


^L7 


Fig.  31- — The  Amnion  Completed. 

a.  The  allantois  completed,  having  carried 
vessels  into  all  the  projections  (villi)  of 
the  chorion,     b.  The  umbilical  vesicle. 


2.  Hypoblast  (Entoderm) ;  epithelium  of  walls  and  glands  of  intestines, 
epithelium  of  lungs  and  air  passages. 

3.  Mesoblast  (Mesoderm)  furnishes  the  corium,  muscles,  bones, 
connective  tissues,  muscular  layers  of  digestive  tract,  blood-vessels, 
and  the  genito-urinary  system. 

What  is  the  allantois? 

A  vascular  mass,  called  the  allantois,  shoots  out  from  the  caudal 
part  of  the  alimentary  canal  of  the  embryo,  and  when  it  has  reached 


PREGNANCY 


49 


the  inner  surface  of  the  ovum,  spreads  out,  carrying  loops  of  blood- 
vessels into  the  villi  of  the  chorion. 

In  what  manner,  then,  does  the  embryo  receive  its  nourishment? 

I.  Before  the  formation  of  the  allantois,  the  nutriment  needed  for 
growth  is  furnished  (a)  by  osmosis  of  fluids  from  the  tissues  of 
.  the  mother  into  the  ovum,  and  (b)  by  the  fluid  materials  of  the 
ovum  contained  within  the  internal  blastodermic  layer.  While 
the  allantois  is  being  formed,  this  internal  layer  contracts,  its 
shrunken  bulk  constituting  the  umbilical  vesicle,  which  finally 
disappears. 


Fig.  32. — Villi  of  Chorion, 


Fig.  33. — Same  as  Fig.  32  but  seen 
with  a  high  power. 


2.  By  the  time  the  allantois  is  fully  formed,  if  not  before,  the  ovum 
has  reached  the  womb.  Its  viUi,  thus  provided  with  blood-vessels, 
become  enlarged  and  arborescent  over  that  part  of  the  ovum  which 
is  in  contact  with  the  uterine  wall,  but  atrophy  and  disappear  from 
the  rest  of  its  circumference. 

3.  When  the  ovum  has  reached  the  uterus,  it  is  detained  in  a  fold  of 
mucous  membrane  and  imbeds  itself  into  it.  The  edges  of  the  fold 
grow  over  the  ovum,  so  as  to  give  it  an  additional  covering  of 
mucous  membrane,  called  the  decidua  reflexa. 

4.  When  the  ovum  is  thus  fastened  to  the  uterine  wall,  the  chorionic 
villi  increase  in  size,  and  form  attachments  to  the  uterine  wall 


50  COMPEND    OF    OBSTETRICS 

underneath  it,  forming  the  placenta,  by  which  a  definite  vascular 
connection  is  established  between  the  embryo  and  mother. 
5.  The   placenta   being   formed,    the   embryo   is   suspended   in   the 
amniotic  sac  by  a  cord  reaching  to  the  placenta,  called  the  funis, 
or  umbilical  cord,  and  continues  to  develop  to  the  end  of  pregnancy. 

What  coverings  has  the   embryo  at  the  period  when  placental 
circulation  is  established? 

First,  the  amnion,  the  membrane  nearest  the  fetal  body. 

Second,  the  chorion. 

Third,  the  decidua  reflexa  and  the  general  uterine  wall. 

What  is  the  length  of  time  taken  by  the  ovum  in  passing  through 
the  oviduct  to  the  uterus? 

From  seven  to  ten  days. 

What  is  the  size  of  the  ovum  on  its  entrance  into  the  uterus? 

From  1/50  to  1/25  of  an  inch. 

What   changes  in  the  mucous  membrane   of  the   womb  follow 
fecundation? 

I.  The  mucous  membrane  of  the  womb  becomes  hyperemic,  and 
hypertrophied;  it  develops  new  and  soft  connective  tissue,  and 
is  thrown  into  folds.  In  this  thickened  state  it  is  called  the 
decidua  vera,  or  uterine  decidua.  (This  occurs  whether  the  ovum 
enters  the  womb  or  not.) 

"2.  When  the  ovum  enters,  adjacent  folds  grow  over  it,  forming  the 
decidua  reflexa,  or  ovular  decidua.  As  the  ovum  increases  in  size, 
the  decidua  reflexa  becomes  united  or  welded  with  the  superficial 
layers  of  the  general  mucous  membrane,  or  decidua  vera  (about 
the  fourth  month). 

3.  That  part  of  the  membrane  directly  under  the  ovum,  and  to  which 
the  placenta  is  attached,  undergoes  greater  changes,  and  is  called 
the  decidua  serotina,  or  placental  decidua. 

Describe  the  development  of  the  placenta. 

I.  The  allantois,  carrying  with  it  the  blood-vessels  which  are  to  con- 
nect the  embryo  with  the  periphery  of  the  ovum,  fuses  with  the 
chorion  and  carries  into  each  villus  of  the  latter  small  loops  of 
blood-vessels.  The  chorionic  villi  atrophy  over  the  whole  ovum 
except  that  part  which  is  in  direct  contact  with  the  decidua 
serotina  (placental  decidua).  The  placenta  is  a  separate  organ  at 
about  the  third  month,  and  during  this  month  its  circulation  is 


PREGNANCY  5 I 

complete.  It  is  composed  almost  entirely  of  fetal  tissue,  the 
chorion  frondosum,  but  when  it  is  thrown  off  after  labor,  the  super- 
ficial layer  of  the  decidua  serotina  separates  with  it,  forming  its 
maternal  surface. 

2.  The  villi  of  the  chorion  frondosum  are  tufts  of  fetal  capillaries 
covered  with  two  (or  more)  layers  of  embryonal  tissue  derived 
from  the  epiblast  (ectoderm)  and  mesoblast  (mesoderm).  The 
inner  of  these  layers  is  composed  of  large  nucleated  cells  (Langhans, 
layer),  while  the  outer  layer  is  simply  a  band  of  protoplasm 
in  which  are  imbedded  nuclei  at  irregular  intervals.  This  outer 
layer  is  called  the  syncytium,  and  is  supposed  to  have  a  phago- 
cytic action.  About  the  third  month  Langhans'  layer  disappears, 
leaving  the  villi  covered  only  by  the  syncytium. 

3.  The  villi  branch  in  every  direction,  and  coming  in  contact  with 
the  inner  surface  of  the  decidua  serotina  often  appear  on  section 
to  have  dipped  down  into  it,  but  that  is  only  apparent  and  does 
not  actually  occur  (Evans). 

4.  The  maternal  capillaries  in  the  superficial  layer  of  the  serotina 
become  immensely  distended  with  blood,  thus  forming  sinuses. 

5.  The  superficial  layer  of  the  decidua  serotina  and  the  walls  of  the 
maternal  capillaries  are  in  time  absorbed,  probably  by  the  phago- 
cytic action  of  the  syncytial  cells,  and  thus  the  maternal  blood  is 
permitted  to  escape  into  the  intervillous  spaces. 

The  fetal  villi  are  now  in  direct  contact  with  the  maternal  blood, 
but  there  is  no  actual  connection  between  the  maternal  and  fetal 
circulations,  as  the  walls  of  the  villi  and  their  coverings  are  still 
interposed. 

Does  the  maternal  blood  enter  the  circulation  of  the  child? 

No.  The  fetus  derives  nutriment  by  endosmosis,  through  the 
delicate  walls  of  the  villi  floating  in  the  maternal  sinuses — like  the 
rootlets  of  a  plant — absorbing  the  elements  needed  for  growth,  and 
discharging  effete  products  by  exosmosis.  According  to  some,  the 
villi  dip  into  crypts  or  depressions  of  the  decidua  serotina  and  not  into 
the  sinuses,  and  absorb  a  secretion  called  uterine  milk,  which  is 
furnished  by  these  crypts. 

What  function  has  the  placenta? 

The  functions  of  the  placenta  are  varied.  In  a  general  way  it  as- 
sumes the  place  of  the  lungs,  alimentary  tract,  liver  and  kidneys.  It 
aerates  the  fetal  blood  supplying  it  with  oxygen.     It  absorbs  nourish- 


52  COMPEND    OF    OBSTETRICS 

ment  from  the  maternal  blood;  it  has  been  shown  by  some  to  have  a 
glycogenic  function  such  as  the  liver  has  in  adult  life  and  it  also  acts 
as  an  organ  of  excretion  for  the  fetus. 

What  is  the  funis,  or  umbilical  cord? 

The  veins  of  the  placenta  ultimately  unite  in  a  single  vein,  which 
passes  to  the  umbilicus  of  the  fetus.  Two  arteries  pass  from  the  fetus 
to  the  placenta,  and  are  wound  spirally  about  the  vein.  These  three 
vessels  are  imbedded  in  a  substance  called  Wharton's  gelatin,  and 
covered  by  a  membrane  derived  from  the  amnion.  The  whole  is 
called  the  funis,  or  umbilical  cord. 

Does  the  fetus  excrete  through  the  bladder  and  bowels  during 
intrauterine  life? 

The  kidneys  begin  to  functionate  about  the  seventh  week.  At  first 
their  ducts  communicate  with  the  rudimentary  allantois  but  as  the 
bladder  is  derived  from  the  allantois,  the  ureters  finally  empty  into 
that  organ.  In  the  course  of  development  urine  is  excreted  as  can 
be  proved  by  the  presence  of  urea  in  the  amniotic  fluid.  Albumin 
to  a  certain  extent  is  always  found  in  fetal  urine.  Edgar  calls  atten- 
tion to  an  important  medico  legal  point  in  connection  with  the  fetal 
kidneys,  namely,  the  appearance  of  dark  yellow  infarcts  which  are 
invariably  present  even  if  the  infant  has  breathed  but  a  short  time 
before  death.  The  bowels  are  normally  inactive  in  intrauterine  life  ex- 
cept in  pathological  conditions  such  as  apoplexy,  coiled  or  compressed 
cord,  etc.  A  discharge  of  meconium  during  labor  should  therefore 
always  be  diagnosed  as  a  danger  signal  except  in  a  normal  breech 
presentation. 

What  are  the  knots  in  the  funis? 

The  fetus  in  its  active  movements  sometimes  passes  through  a 
loop  of  the  funis,  and  this,  when  drawn  tight,  forms  a  true  knot. 
False  knots  are  mere  knobs  or  masses  of  Wharton's  gelatin,  formed  at 
intervals  along  the  cord. 

What  are  the  dimensions  of  the  placenta  and  funis  at  full  term? 

The  placenta  is  about  9  inches  in  diameter,  and  weighs  i 
pound.  The  funis  or  umbilical  cord  averages  about  20  inches,  the 
extremes  being  from  3  to  4  inches  in  length. 

Describe  the  fetal  circulation. 

The  blood  is  propelled  from  the  left  ventricle  of  the  fetus  through 


PREGNANCY  53 

the  aorta  and  iliac  arteries  to  the  point  where  the  umbiHcal  arteries  are 
given  off  r  through  these  to  the  placenta,  and  back  again  through  the 
umbilical  vein,  to  the  liver,  where  most  of  the  blood  passes  through 
the  portal  circulation  and  empties  by  the  hepatic  vein  into  the  vena 
cava;  the  remainder,  passing  through  the  ductus  venosus,  empties 
directly  into  the  vena  cava  without  passing  through  the  liver.  From 
this  it  enters  the  right  auricle,  and  is  deflected  by  the  Eustachian  valve, 
through  the  foramen  ovale,  into  the  left  auricle,  and  thence  into  the 
left  ventricle.  The  blood,  returning  from  the  head  and  upper  ex- 
tremities, passes  from  the  right  auricle  to  the  right  ventricle;  to  the 
pulmonary  artery  through  the  ductus  arteriosus,  into  the  aorta.  It 
will  be  noticed  that  the  venous  blood  of  the  fetus  is  more  oxygenated 
than  the  arterial.  After  birth  the  foramen  ovale  closes  and  the 
peculiarly  fetal  vessels  disappear. 

What  are  the  characteristics  of  fetal  blood? 

In  the  early  months  of  fetal  life  the  fetal  blood  contains  nucleated 
redvblood  corpuscles  plainly  distinguishable  from  those  of  the  mother. 
At  first  these  are  few  in  number  but  they  rapidly  increase.  About 
the  third  month  the  majority  of  these  cells  have  been  replaced  by 
non-nucleated  corpuscles  similar  to  those  of  the  adult.  The  relative 
quantity  of  the  blood  in  the  fetus  and  placenta  varies;  at  first  the 
placenta  has  the  larger  amount;  later  the  fetus  and  placenta  have 
about  equal  amounts,  while  toward  the  end  of  fetal  life  the  fetus  has 
considerably  more  blood  than  the  placenta. 

The  arterial  blood  pressure  in  the  fetus  is  about  half  that  of  the  newly 
born  child  while  the  pressure  in  the  veins  is  much  higher. 

What  is  the  amnion? 

It  is  the  membranous  covering  next  the  childs  body.  At  first  it 
encloses  only  the  dorsal  part  of  the  embryo  but  with  the  growth  and 
closure  of  the  body  wall  round  the  umbilicus  it  completely  invests  the 
embryo,  except  that  the  umbilical  cord  passes  through  it.  It  is 
continuous  with  the  fetal  epidermis  at  the  umbilicus.  It  consists  of 
two  layers,  one  of  flattened  cells  derived  from  the  ectoderm  and 
continuous  with  the  epidermis,  the  other  of  connective-tissue  cells,  of 
mesoblastic  (mesodermic)  origin.  The  enclosed  space  between  the 
two  layers  constitutes  the  true  amniotic  sac  and  its  chief  function  is 
the  secretion  of  the  liquor  amnii.  At  first  the  amnion  as  compared 
with  the  embryo  is  quite  large  but  the  embryo  grows  rapidly  and  the 
amnion  closely  invests  it.     At  about  the  second  month  a  rapid  growth 


54  COMPEND    OF    OBSTETRICS 

of  the  amnion  takes  place  which  results  in  a  close  relationship  between 
it  and  the  chorion.  As  long  as  a  space  exists  between  the  amnion 
and  chorion  the  latter  is  filled  with  fluid  somewhat  resembling  am- 
niotic fluid.  This  is  called  the  false  amniotic  cavity.  At  birth  the 
hag  of  water  consists  of  the  amnion  and  part  of  the  chorion, 

"What  is  the  liquor  amnii? 

A  clear,  slightly  saline  fluid,  secreted  from  the  inner  surface  of  the 
amnion,  and  in  which  the  embryo  floats.  ^ 


a.s. 


p.m. 


y.s. 


Fig.  34. — Ruptured  Human  Ovum  Fifteenth  to  Eighteenth  Day.    Amnion  has 
been  opened.     a,s.,   Allantois  stalk;  p.m.,  parietal  mesoblast;  _y,s.,  yolk-sac;  a., 
amnion;  h.,  heart. — (Coste.) 

How  much  liquor  amnii  is  found  at  full  term? 

From  half  an  ounce  to  several  pints.  The  average  is  about  a  liter  or 
pint.  It  is  alkaline  in  reaction,  with  a  specific  gravity  of  about  1028 
and  consists  of  water  about  99  per  cent.,  a  trace  of  albumin,  creatin, 
epithelial  cells,  sebaceous  material,  urea  and  some  inorganic  salts. 
It  may  vary  in  color  from  an  opaque  white,  greenish  brown  due  to  the 
presence  of  meconium  or  in  some  cases  where  the  fetus  is  dead 
and  macerated  it  is  said  to  have  been  of  a  reddish  color. 


PREGNANCY  55 

What  are  the  functions  of  the  liquor  amnii? 

1 .  It  saves  the  uterus  from  the  injurious  effects  of  the  fetal  movements. 

2.  It  aids  in  distending  the  uterus  and  allows  freedom  of  movement 
to  the  fetus. 

3.  Prevents  adhesions  between  the  fetus  and  amnion  thus  tending 
to  prevent  fetal  abnormalities  and  monstrosities. 

4.  It  prevents  the  fetus  from  external  violence  such  as  blows  on  the 
mother's  abdominal  walls. 

5.  It  serves  to  maintain  the  fetus  at  an  equable  temperature. 

6.  It  serves  to  receive  and  dilute  the  fetal  excretions.  It  is  said  by 
some  that  it  is  a  source  of  nourishment  to  the  fetus.  This  however 
is  not  generally  believed. 

7.  It  is  possible  that  it  supplies  to  the  fetus  by  absorption  a  certain 
amount  of  water. 

8.  It  forms  one  of  the  best  possible  hydraulic  dilators  for  the  cervix 
during  labor. 

9.  After  rupture  of  the  bag  of  water  and  its  escape  during  labor  it 
acts  as  a  lubricant  and  cleanser  of  the  external  birth  canal. 

In  a  healthy  woman  whose  uterine  cavity  has  not  been  infected 
previous  to  pregnancy  the  amniotic  fluid  is  sterile. 

How  is  the  chorion  formed? 

The  outer  surface  of  the  external  blastodermic  layer  or  that  part 
which  did  not  follow  the  embryo  within  the  ovum,  now  becomes 
covered  with  small  shaggy  tufts  which  are  the  primitive  chorionic 
villi. 

Later  the  chorion  develops  a  mesodermic  lining.  The  outer  layer 
is  covered  by  villi  showing  slight  cavities  at  their  bases  into  which 
the  mesoderm  protrudes.  The  villi  extend  into  the  uterine  mucous 
membrane  in  such  a  way  as  to  indicate  that  epithelium,  glands  and 
walls  of  blood-vessels  in  this  part  are  disintegrated  and  they  pro- 
trude freely  into  the  maternal  blood.  At  a  later  period  the  villi  are 
grouped  in  a  band  leaving  the  two  flattened  poles  of  the  ovum  bare. 
At  a  still  later  period  each  villus  is  filled  with  a  tuft  of  blood-vessels 
derived  from  the  mesoderm.  The  club-shaped  villi  of  the  early  ovum 
soon  begin  to  degenerate  on  the  side  next  to  the  decidua  reflexa 
until  that  part  of  the  chorion  is  smooth.  This  is  called  the  chorion 
IcRve.  On  the  smooth  area  of  the  chorion  next  to  the  decidua  sero- 
tina  the  villi  become  greatly  enlarged  and  much  branched,  the  embry- 
onic blood-vessels  following  each  ramification.     This  is  called  the  chor- 


56  COMPEND    OF    OBSTETRICS 

ion  frondosum  and  becomes  the  fetal  part  of  the  placenta.  The  cells 
of  the  outer  layer  of  the  epithelium  develop  rapidly,  do  not  sepa- 
rate and  form  the  Syncytium. 

What  is  the  decidua  reflexa? 

The  decidua  reflexa,  circumflexa  or  capsularis  or  epichorial 
decidua  (Edgar)  is  not  as  its  name  indicates  reflected  but  is  formed 
by  growth  of  the  uterine  tissues  over  the  ovum  until  they  meet  above 
its  surface. 

The  decidua  vera  is  thickest  at  the  third  month  of  pregnancy  after 
which  it  steadily  becomes  thinner.  In  early  pregnancy  the  ovum  does 
not  completely  fill  the  uterine  cavity  but  when  this  comes  about  the 
vera  is  compressed  and  begins  to  atrophy  while  the  reflexa  comes  into 
closer  and  closer  contact  with  it.  At  about  the  sixth  month  the  two 
deciduae  cannot  be  distinguished.  Until  the  fusion  of  these  two  parts 
of  the  decidua  the  interval  between  them  is  filled  with  fluid  much 
like  the  liquor  amnii.  During  the  later  months  of  pregnancy  the 
decidua  undergoes  a  fatty  degeneration  that  assists  in  loosening  its 
attachment  to  the  uterus.  The  greater  part  of  this  membrane  is  cast 
off  during  labor.  That  part  of  it  remaining  in  the  uterus  after  labor 
is  discharged  in  the  lochia  except  a  small  part  which  assists  in  the 
formation  of  a  new  uterine  mucosa. 

How  large  is  the  ovum  (and  fetus)  in  different  months? 

By  the  end  of  the  first  lunar  month  of  pregnancy  the  ovum  is 
about  the  size  of  a  pigeon's  egg. 

End  of  2d  month,  size  of  a  hen's  egg;  fetus  an  inch  long. 

End  of  3d  month,  size  of  a  goose  egg;  fetus  3  inches  long. 

End  of  4th  month,  the  fetus  is  6.6  inches  long. 

End  of  5th  month,  the  fetus  is  7-10  1/2  inches  long. 

End  of  6th  month,  the  fetus  is  11-13  inches  long. 

End  of  7th  month,  the  fetus  is  13. 7-1 5  inches  long. 

End  of  8th  month,  the  fetus  is  15-17  inches  long. 

End  of  9th  month,  the  fetus  is  16-17  1/2  inches  long. 

End  of  loth  month,  the  fetus  is  17  1/2-18  1/2  inches  long. 

[According  to  Schroeder.]  American  children  are  usually  larger 
at  birth. 

How  soon  can  the  sex  of  a  child  be  recognized? 

Not  certainly  until  during  the  fourth  month. 


PREGNANCY 


57 


What  is  vernix  caseosa? 

An  unctuous  sebaceous  secretion  covering  the  skin  of  the  child 
for  the  purpose  of  lubricating  it  for  delivery.  It  does  not  appear 
until  the  seventh  month. 

What  is  meconium? 

The  dark-green-^  semi-fluid  contents  of  the  fetal  intestine,  corre- 
sponding to  fecal  matter  in  the  adult.  It  contains  granular  bodies, 
called  meconium  granules,  the  presence  of  which  is  characteristic 
of  meconium. 


Fig.  35. 

What  changes  occur  in  the  womb  itself  during  pregnancy? 

It  enlarges  greatly,  to  accommodate  the  growing  ovum,  and  at 
the  end  of  pregnancy  has  a  weight  of  2  pounds,  and  its  cavity 
is  a  foot  in  diameter.  In  the  non-pregnant  state  the  uterus  is  the 
shape  of  a  pear  flattened  much  in  its  anterior  posterior  diameter.  Quite 
early  in  pregnancy  it  becomes  more  rounded  and  as  it  advances  the 


58  COMPEND    OF    OBSTETRICS 

uterus  becomes  the  shape  of  an  inverted  jug.  As  the  fetus  begins  to 
distend  the  uterine  cavity,  the  uterine  wall  becomes  thinned.  The 
lower  uterine  segment  also  forms  in  pregnancy.  The  cervix  enlarges 
but  little  (not  more  than  one-half),  and  its  cavity  remains  separate 
until  the  last  week  or  weeks  of  pregnancy,  when  the  os  internum  may 
be  stretched  partially  open  and  the  cavities  of  the  cervix  and  body  of 
the  uterus  become  one.  The  tissue  of  the  cervix  becomes  softer  to 
the  touch. 

What  changes  in  position  does  the  womb  undergo? 

During  the  first  month  the  increased  weight  of  the  uterus  causes 
it  to  descend  somewhat  in  the  pelvis,  or  become  slightly  prolapsed. 
End  of     2d  mo.     Still  low  in  the  pelvis,  and  unusually  anteverted. 

Bimanual  touch  shows  it  to  be  as  large  as  a  small 
orange. 

The  same,  but  as  large  as  a  child's  head. 

Fundus  can  be  felt  just  above  the  symphysis,  and, 
being  too  large  for  the  pelvis,  it  now  ascends. 

Fundus  midway  beteen  umbilicus  and  symphysis. 

Fundus  at  level  of  umbilicus. 

Fundus  2  to  3  1/2  fingers'  breadth  above  umbilicus. 

Fundus  I  to  2  fingers'  breadth  below  ensiform  ap- 
pendix. 

Fundus  touches  the  ensiform  appendix. 

Fundus  has  descended  to  same  position  as  in  eighth 
month. 

Why  does  the  fundus  of  the  uterus  descend  during  the  last  month? 

Because  the  cavity  of  the  cervix  is  added  to  that  of  the  fundus 
at  that  time,  and  the  contents  of  the  womb  settle  toward  the  pelvis, 
leaving  more  room  above. 

MULTIPLE  PREGNANCY 

How  many  children  may  a  woman  have  at  one  time? 

Two,  or  twins;  three,  or  triplets;  four,  or  quadruplets;  five,  or 
quintuplets. 

How  frequently  do  multiple  births  occur? 

Twins,  once  in  eighty -nine  cases;  the  others  are  rare,  and  any  over 
five  are  apocryphal. 


End  of 

3d  mo. 

End  of 

4th  mo. 

End  of 

5  th  mo. 

End  of 

6th  mo. 

End  of 

7th  mo. 

End  of 

8th  mo. 

End  of 

9th  mo. 

End  of 

lothmo. 

PREGNANCY  59 

How  are  mutliple  pregnancies  caused? 

1.  Two   or   more  ova  may  be  fecundated  and  simultaneously   de- 
veloped. 

2.  Two  primitive  traces  may  appear  on  one  ovum,  and  each  develop 
an  embryo. 

These  two  causey  may  be  combined  in  the  case  of  triplets,  etc. 

How  may  the  cause  be  demonstrated? 

Twins  developed  from  separate  ova  will  each  have  its  own  placenta 
and  membranes;  from  a  single  ovum  will  have  a  single  placenta, 
and  usually  but  one  set  of  membranes,  though  there  may  be  two 
amniotic  sacs. 

"What  is  superimpregnation? 

The  impregnation  of  two  or  more  ova  at  the  same  coitus.  It  is 
simultaneous  fecundation. 

What  is  superfecundation? 

The  fecundation  of  two  ova  within  a  short  period  of  one  another 
but  not  at  the  same  coitus. 

How  is  this  demonstrated? 

By  cases  in  which  a  woman  has  borne  twins,  one  white,  the  other 
a  mulatto,  from  separate  intercourse  with  a  white  man  and  a  negro. 

What  is  superfetation? 

The  fecundation  of  a  second  ovum  after  a  first  ovum  has  entered 
the  uterus.  It  may  occur  during  the  first  four  months  of  pregnancy, 
or  before  the  decidua  refiexa  and  decidua  vera  have  become  united. 

How  is  this  demonstrated? 

1.  By  cases  in  which  the  birth  of  a  fully  developed  child  has  been 
followed  by  a  second  birth,  after  an  interval  of  one,  two,  three, 
or  four  months. 

2.  By  the  expulsion  at  one  birth  of  a  fully  developed  child  and  a 
fetus  evidently  one  or  more  months  less  advanced  in  develop- 
ment. 

3.  By  the  extra-  and  intra-uterine  pregnancies  occurring  simulta- 
neously. 

What  is  the  clinical  course  of  twin  pregnancy? 

1.  Both  children  may  be  safely  carried  to  term. 

2.  Both  children  may  be  prematurely  expelled. 


6o  COMPEND    OF    OBSTETRICS 

3.  One  twin  may  be  prematurely  expelled  and  the  other  remain 
until  born  at  term. 

4.  One  twin  may  die  in  utero  and  be  retained  until  the  birth  of  the 
other. 

PATHOLOGY  OF  PREGNANCY 

What  is  morning  sickness? 

Nausea  and  vomiting,  just  after  rising  in  the  morning.  It  is 
usually  limited  to  the  early  months  of  pregnancy,  or  when  the  volume 
of  blood  is  not  yet  increased,  although  there  is  not  enough  for  mother 
and  child.  It  is,  therefore,  due  to  the  want  of  sufficient  blood, 
and  the  consequent  cerebral  anemia  due  to  the  sudden  change  in  the 
circulation  upon  awakening  from  sleep  and  resuming  the  upright 
position.  The  cause,  probably,  is  the  same,  as  produces  other  reflex 
disturbances  at  this  time — namely,  a  sympathetic  disturbance  caused 
by  the  stretching  of  the  uterine  fibers  by  the  growing  ovum  and 
consequent  irritation  of  the  uterine  nerv^es. 

A  similar  form  of  vomiting  is  sometimes  met  with  at  other  times 
of  the  day,  after  special  exertion,  and  especially  mental  effort.  With 
the  morning  nausea  not  infrequently  there  will  be  anorexia  or  dislike 
for  certain  articles  of  food  or  craving  for  others.  Constipation  due  to 
lack  of  intestinal  peristalsis  may  coexist.  The  typical  morning  nausea 
may  begin  with  conception  but  it  is  most  commonly  seen  about  the 
sixth  week  and  lasts  three  or  four  weeks. 

How  should  morning  sickness  be  treated? 

It  is  sometimes  relieved  by  slowness  in  arising,  and  by  taking 
a  cup  of  coffee  before  rising,  and  may  be  cured  by  the  use  of  nutrients 
and  blood-making  agents.  It  is  best  treated  by  the  recumbent  posi- 
tion and  a  light  diet  of  small  quantities  of  food  at  a  time.  The  food 
should  be  easily  digested  and  have  little  waste. 

What  is  the  "vomiting  of  pregnancy?" 

Continuous  or  protracted  vomiting  in  pregnancy  depends — 

1.  On  the  deficiency  and  deterioration  of  the  blood. 

2.  The  irritable  condition  of  the  nerve  centers,  due  to  their  impov- 
erishment from  defective  blood  supply. 

3.  To  an  exciting  cause,  such  as  disease  of  the  uterus,  acting  with 
the  other  sources. 

4.  Hysteria. 


PATHOLOGY   OF   PREGNANCY  6 1 

5.  Compression  of  uterine  nerves  due  to  the  increasing  size  of  the 
organ. 

6.  Autointoxication. 

What  are  the  indications  for  treatment  in  severe  vomiting? 

1 .  To  remove  any  sources  of  irritation  which  may  coexist  with  the 
general  state  of  the  blood.  Thus,  inflammation  and  abrasions 
of  the  cervix  uteri  may  exist  in  some  cases,  and  their  removal 
by  proper  applications  may  cure  it.  Malposition  of  the  uterus 
should  be  corrected. 

2.  To  control  the  irritability  of  the  nerve  centers,  which  may  be 
done  by  rectal  enemata  of  chloral  and  bromid  of  potassium. 

3.  To  improve  the  blood  supply,  by  administering  nourishing  fluids 
in  small  quantit^'es,  frequently  repeated,  beginning  with  milk  and 
lime  water  or  better  the  use  of  predigested  foods,  peptonized, 
milk,  panopeptone,  etc. 

4.  When  nothing  can  be  borne  on  the  stomach  rectal  feeding  may 
be  resorted  to  for  a  short  time. 

5.  Small  quantities  of  dry  champagne,  or  the  carbonated  water  may 
be  used   by  the  mouth.     Some  advise  that  the  fauces  should  be 

sprayed  with  a  solution  of  cocain  before  eating.  In  this  form  of 
vomiting  as  in  others  we  have  found  an  occasional  gastric  lavage 
of  great  use ;  a  solution  of  sodium  bicarbonate  5  ii  to  the  quart  being 
used.  The  patient  should  always  be  in  bed.  Bowel  irrigation  of  4 
quarts  of  normal  saline  solution  may  do  good.  A  certain  amount  of 
this  should  be  retained. 

In  mild  cases  any  of  the  antiemetics  may  be  used,  as  the  oxalate 
of  cerium,  with  or  without  the  subnitrate  of  bismuth,  or  minute 
doses  of  cocain  or  carbolic  acid.  We  have  used  with  good  effect 
in  some  of  these  cases  the  following: 

Cocain  hydrochlorate   gr.  1/4 

Acid  carbolic gr.  i 

Cercium  oxalate gr.  v 

Sacch.  lact gr.  x 

and  repeat. 
This  should  be  given  before  taking  food. 

What  is  meant  by  the  pernicious  vomiting  of  pregnancy? 

Pernicious  vomiting   of  pregnancy,    or  hyperemesis   gravidarum, 
consists  in  an  intense  aggravation  of  the  usual  nausea  of  gestation. 


62  COMPEND    OF    OBSTETRICS 

The  vomiting  is  intense  and  persistent  and  is  accompanied  by  all 
the  symptoms  of  the  profound  toxemia  or  autointoxication.  It 
usually  causes  death  unless  relief  is  afforded. 

What  are  its  causes? 

Probably  an  aggravation  of  those  producing  the  usual  nausea 
and  vomiting  of  pregnancy. 

What  are  its  characteristic  symptoms? 

The  nausea  and  vomiting  become  constant  and  more  and  more 
severe.  The  vomited  matter  is  first  composed  of  food  mixed  with 
bile  and  mucus,  and  in  the  later  stages  with  blood  (coffee-ground 
vomit).  The  patient  rapidly  becomes  weak  and  emaciatfed;  the 
expression  is  anxious.  As  the  disease  progresses  there  is  continuous 
fever,  weak  pulse,  dry  skin,  throat  and  tongue  dry,  and  breath 
foul.  Thirst  is  excessive.  The  urine  is  scanty  and  high  colored; 
albumin  may  be  present  and  the  amount  of  solid  excretion  is  re- 
duced. The  urine  may  show  the  peculiarities  found  in  any  other 
form  of  the  toxemia  of  pregnancy  (see  Toxemia  of  Pregnancy). 
Acetone  and  diacetic  acid  may  be  found  in  it,  this  is  not  necessar- 
ily due  to  the  toxemia  but  may  be  from  starvation.  Diarrhea  is  a 
common  symptom.  Nausea  and  vomiting  are  continuous.  There 
is  pain  in  the  head,  over  the  stomach,  or  at  the  tip  of  the  ster- 
num. The  extremities  become  cold  and  clammy.  Later  the  fever 
increases,  the  pulse  becomes  small  and  thin — 130  to  1 60.  Delirium, 
syncope,  or  coma  end  the  patient's,  life. 

How  would  you  diagnosticate  pernicious  or  toxemic  nausea? 

The  diagnosis  is  not  easy  and  must  be  made  by  a  thorough  examina- 
tion of  the  patient  and  her  excretions,  particularly  the  urine,  after  hav- 
ing excluded  all  neurotic  elements  and  uterine  displacements.  Wil- 
liams claims  that  in  cases  of  toxemic  nausea  that  great  help  can  be  ob- 
tained by  a  study  of  the  ammonia  coefficient — the  relation  of  the 
nitrogen  as  contained  in  the  ammonia  to  the  total  nitrogen  content  of 
the  uterine.  Normally  this  varies  between  3  to  5  per  cent,  but 
under  patholog^'cal  condition  may  rise  as  high  as  30,  40  to  50  per  cent. 
These  estimations  require  special  apparatus  and  are  difficult.  In  our 
own  experience  they  have  not  been  constant.  A  careful  study  of  the 
blood  pressure  should  also  be  made.  We  believe  that  in  the  majority 
of  cases  if  no  amelioration  of  the  symptoms  results  after  several  days 
of  rest,  gastric  and  intestinal  lavage  and  rectal  feeding,  the  uterus 
should  be  emptied  of  its  contents. 


PATHOLOGY  OF  PREGNANCY  6$ 

What  is  the  treatment  of  the  pernicious  vomiting  of  pregnancy? 

The  principal  indications  are  rest  in  bed,  with  the  patient's  head 
low.  Almost  all  drugs  have  been  used  with  varying  results.  All 
urine  displacements  should  be  corrected.  Cocain  or  menthol  may  be 
applied  to  the  cervix.  An  ice-bag  may  be  applied  to  the  abdomen. 
Rectal  feeding  may  be  resorted  to  if  no  food  can  be  retained  by  the 
mouth.  If  all  these  measures  fail  and  the  patient  is  becoming  ex- 
hausted, the  pregnancy  should  be  promptly  terminated. 

ABORTION  AND  PREMATURE  LABOR 

What  is  meant  by  abortion,  miscarriage,  and  premature  labor? 

Abortion  is  properly  the  premature  expulsion  of  the  fetus  before 
it  is  viable;  when  occurring  during  the  first  three  weeks  it  is  known 
as  ovular;  up  to  the  fourth  month  embryonic;  after  the  fourth  month 
fetal  abortion.  It  is  also  subdivided  into  spontaneous  and  artificial, 
the  latter  including  (a)  therapeutic,  and  (b)  criminal.  Abortion 
is  described  as  complete  when  the  whole  ovum  is  thrown  off,  and 
incomplete  when  part  of  the  ovum  is  retained  within  the  uterus. 
In  threatened  abortion  the  amount  of  ovular  detachment  is  slight. 
In  inevitable  abortion  there  is  extensive  detachment  or  rupture  of  the 
ovum  with  death  of  the  fetus.  Abortion  in  successive  pregnancies 
is  known  as  habitual.  Missed  abortion  is  when  the  fetus  is  retained 
in  the  uterine  cavity  for  months  or  years  after  its  death.  Premature 
labor  is  the  expulsion  of  the  fetus  after  viability,  but  before  full 
term.  The  older  writers  restricted  the  term  abortion  to  the  period 
before  quickening  (the  child  not  being  supposed  to  be  living  until 
then),  and  miscarriage  to  the  period  between  quickening  and  viability. 
The  term  miscarriage  is  now  usually  applied  to  expulsion  of  the 
product  of  conception  between  the  fourth  and  seventh  months  or 
after  the  placenta  is  formed;  after  that  time  it  is  known  as  premature 
labor. 

What  is  meant  by  the  term  viable? 

A  child  born  after  seven  lunar  months  of  pregnancy  may  live, 
and  is  called  viable — livable. 

What  are  the  causes  of  spontaneous  abortion? 

Disease  or  injury  (i)  to  the  ovum  or  fetus,  ovular. 
Disease  or  injury  (2)  to  the  mother,  maternal. 
Disease  in  the  father  (3),  paternal, 
as 

5 


64  COMPEND    OF    OBSTETRICS 

(i)  Ovular — - 
(a)  Syphilis. 

(&)   Placental  apolexy  and  detachment,  from  hemorrhage, 
(c)    Placental    degeneration;    amyloid    or    fatty      (cystic,    vide 
hydatids). 

{d)  Dropsy  of  amnion. 

{e)  Violence,  accidental  rupture  of  the  membranes,  etc.  The 
death  of  the  fetus  from  any  cause  is  not  always  followed  by 
its  premature  expulsion. 

(2)  Maternal — 

(a)  Hyperemia  of  the  pelvic  organs  from  over-exercise,  coitus, 
lifting,  use  of  sewing  machine,  displacements  of  the  uterus. 

{h)  Irritation  of  the  uterus,  as  from  tumors,  mental  shock, 
high  temperature  in  fevers.  Changes  in  the  endometrium 
and  placenta  due  to  the  toxaemia  of  pregnancy  or  nephritis. 

(3)  Paternal — 

(a)  Syphilis,     {h)  Coitus. 

When  may  artificial  abortion  or  premature  labor  be  induced? 

Where,  after  due  consultation,  it  is  determined  that,  in  the  first 
case,  the  mother's  life,  and  in  the  second,  the  life  of  either  mother 
or  child,  or  of  both,  are  in  danger. 

Name  some  special  indications  for  therapeutic  artificial  abortion. 

Eclampsia,  obstinate,  uncontrollable  vomiting  of  pregnancy,  bad' 
and  persistent  cases  of  nephritis,  advanced  cases  of  uterine  tumors, 
placenta  praevia.  Pulmonary  tuberculosis  rapidly  advancing  and  in 
some  cases  of  heart  disease.  Premature  labor  may  be  induced  in 
cases  of  pelvic  narrowing,  where  for  any  reason  symphysiotomy 
or  Cesarean  section  cannot  be  performed  at  term,  where  eclampsia 
is  present  or  expected;  in  cases  of  habitually  large  fetal  head  or 
premature  ossification  of  cranial  bones;  and  in  any  condition  gravely 
threatening  the  life  of  mother  and  child.  (For  method  of  inducing 
premature  labor  see  chapter  on  "Induction  of  Labor.") 

What  are  the  symptoms  of  abortion? 

1.  Pain,  more  or  less  constant,  felt  in  the  back,   hypogastrium,   or 
ovarian  regions. 

2.  Uterine  contractions. 

3.  Hemorrhage. 

4.  Dilatation  of  the  os  uteri,  with  softening  of  the  cervix. 


PATHOLOGY    OF    PREGNANCY 


65 


What   is    differential    diagnosis    between   threatened,    inevitable, 
incomplete,  and  complete  abortion? 


Threatened 
Abortion. 


Inevitable 
Abortion. 


Incomplete 
Abortion. 


Complete 
Abortion. 


Hemorrhage,  usu- 
ally slight  and 
free  from  clots. 


Pain  not  marked. 


Hemorrhage,  pro- 
fuse and  con- 
tinuous, clotted 
and   dark   colored, 


Pain  cramp-like  and 
severe. 


Hemorrhage,  per- 
sistent, at  times 
profuse,  at  others 
scanty;  dark 

colored,     and      of- 
fensive. 


Occasional  attacks 
of  paiii  may  be 
present. 


Entire     cessation 
of  hemorrhage. 


Entire   cessation  of 
pain. 


Os     slightly     patu- 
lous. 


Cervical    canal    di- 
lated. 


Cervical  canal  di- 
lated enough  to 
admit  finger, 

which  feels  parts 
of  decidua,  mem- 
branes, or  blood 
clot. 


Os  retracted. 


Uterus  soft  and 
enlarged,  show- 
ing angle  of  ante- 
flexion between 
upper  and  lower  ments  effaced, 
segment. 


Uterus  soft  and 
enlarged;  angle 
between  upper  and 
lower  i.uterine   seg- 


Uterus,  soft,  large, 
and  baggy;  not 
involuting. 


Discharge  is  bright 
colored  blood. 


All    signs    of    preg-   All    signs    of    preg- 
nancy present  ex-      nancy   present  ex- 


Discharge  is  dark 
blood,  clots,  and 
portions  of  ovum. 


Examination  of  dis- 
charged material 
shows  only  frag 
mentary  parts  of 
ovum. 


Uterus      large 
retracted  and  firm. 
Involution         pro- 
ceeding naturally. 


Discharge  is  or- 
dinary lochia, 
which       gradually 


cept   amenorrhea. 


cept     amenorrhea, 


Signs  of  pregnancy 
arrested. 


Subsidence  of  signs 
of  pregnancy  and 
possible  establish- 
ment of  milk  secre- 
tion. 


What  are  the  dangers  of  abortion? 

Hemorrhage;  often  great,  because  of  the  difficulty  with  which  the 

ovum  is  separated  from  the  womb. 

Retention  of  the  placenta,  in  whole  or   in  part,  with  subsequent 

septicemia,  hemorrhage,  and  other  dangers. 

The  womb  is  apt  to  remain  enlarged   (see  Subinvolution),  and 

uterine  disease  may  result. 

Pelvic    and    peritoneal    inflammation    are    more    common    after 

abortion. 


66  COMPEND    OF    OBSTETRICS 

When  are  the  dangers  of  abortion  most  experienced? 

In  the  middle  third  of  the  pregnancy.  In  the  first 
three  months  the  ovum  is  usually  expelled  entire,  and 
the  chief  danger  is  from  hemorrhage  during  the  slow- 
process  of  dilating  the  os  uteri.  In  the  next  third,  the 
attachments  of  the  placenta  are  firmer  than  at  any  other 
time;  the  fetus  is  first  expelled,  and  the  placenta  often 
expeUed  with  great  difficulty  and  piece-meal,  combining 
all  the  risks  at  their  greatest.  In  the  last  three  months 
the  process  differs  but  little  from  normal  labor,,  except 
in  being  slower. 

g  What  are  the  chief  indications  for  treatment? 

p  I .  If  the  patient  is  seen  in  time,  rest  in  bed,  cold  drinks, 

y  bromids,  hypodermic  injections  of  morph.  sulph.  gr. 

o  one-sixth,  or  a  rectal  suppository  of  i  grain  aqueous 

o  extract  opium,  and  a  light  diet.     The  administration 

J  of  the  fluid  extract  of  viburnum  prunifolium  combined 

^  with  opiates  is  sometimes  useful.     The  cause  should 

w  be    searched    for    and    treated.     Failing   in  this,  the 

p  indications  are: 

OS         2.  To  control  hemorrhage. 

w 

J         3.  To  secure  complete  expulsion  of  the  uterine  contents. 

< 

9  How  is  hemorrhage  to  be  managed? 

vo  I.  By  applying  a  tampon,  under  strict  antiseptic  pre- 

cautions,  until  the  os  is  sufficiently  dilated. 

^  2.  By  securing  complete  delivery  and  stimulating 
uterine  contractions. 

How  is  retained  placenta  to  be  managed? 

The  placenta  must  be  detached  by  the  fingers  or 
curet,  as  soon  as  possible  after  the  expulsion  of  the 
fetus.  If  pressure  is  made  by  one  hand  in  the  hypo- 
gastric region,  the  womb  can  usually  be  forced  down 
low  enough  to  enable  the  finger  to  reach  to  the  fundus. 
A  very  good  method  of  removing  the  placenta  is  by 
gently  scraping  it  from  the  uterus  by  means  of  the 
douche  curet  of  Braun,  a  hot  antiseptic  fluid  of  car- 
bolic acid  1:40,  creolin  or  lysol  5j  to  the  quart  being 
passed  from  a  fountain  syringe  through  the  curet  dur- 


PATHOLOGY  OF  PREGNANCY  67 

ing  the  operation.     A  strip  of  antiseptic  gauze  should   be  carried 
to  the  fundus  and  the  vagina  tamponed  carefully 

How  would  you  induce  therapeutic  abortion? 

Either  one  of  two  methods  may  be  employed: 

1.  If  the  patient  is  in  early  pregnancy  and  the  abortion  must  be 
done  at  one  sitting,  and  the  cervix  is  moderately  soft  it  may  be 
dilated  by  the  Hegar  dilators.  The  whole  aseptic  hand  covered 
by  a  rubber  glove  should  be  inserted  into  the  vagina,  one  or  two 
fingers  inserted  into  the  uterus  should  detach  the  ovum  after  which 
the  cavity  should  be  cleaned  by  the  finger  or  dull  curet  and 
washed  out. 

2.  If  the  cervix  is  not  dilated  or  if  sufficient  time  may  be  taken,  the 
cervix  may  be  dilated  sufficiently  to  admit  a  strip  of  sterile  gauze, 
the  vagina  should  be  packed  with  the  same.  This  will  usually 
insure  softening  of  the  cervix  and  the  institution  of  uterine  con- 
traction which  later  will  expel  the  ovum.  If  the  ovum  is  expelled 
entire  the  cavity  should  be  washed  out  with  sterile  salt  solution 
or  lysol  2  per  cent. ;  if  the  placenta  remains,  a  second  packing  of 
the  uterus  will  usually  cause  its  expulsion  or  the  uterine  cavity 
be  cleaned  out  by  the  finger  or  a  dull  curet  with  irrigation. 
The  advantages  of  the  slower  method  are  that  it  is  less  apt  to  be 
followed  by  secondary  hemorrhage,  the  small  placenta  having  time 
to  become  separated  and  the  natural  thrombi  form  in  the  placental 
site.  A  thorough  cleansing  of  the  vulva  and  shaving  of  the  pubic 
hair  should  precede  the  operation  and  an  aseptic- <  vulvar  pad 
should  be  used  over  the  external  genita]  organs.  A  light  packing 
of  the  vagina  may  insure  drainage.  After  uterine  contractions 
have  started,  the  extract  of  pituitrin  given  hypodermically  may 
hasten  the  expulsion  of  the  ovum. 

What  rule  should  guide  us  in  difficult  cases? 

To  persevere  in  efforts  to  remove  the  placenta  as  long  as  we  are 
sure  that  our  efforts  are  less  injurious  than  allowing  it  to  remain. 

What  is  to  be  done  when  the  placenta  cannot  be  removed? 

1.  Use  frequent  antiseptic  injections. 

2.  Employ  remedies  to  guard  against  inflammation  and  septicemia. 

3.  Renew  efforts  to  remove  the  placenta  every  day. 

What  causes  premature   detachment  of  the  placenta   (accidental 
hemorrhage)? 

External  violence  and  irregular  contractions  of  the  womb. 


68  COMPEND    OF    OBSTETRICS 

Diseases  of  the  decidua,  a  very  short  umbilical  cord  may  cause 
it  also.     It  is  said  to  be  more  common  in  multipara  than  primipara. 

What  symptoms  does  it  cause  and  why? 

Hemorrhage  and  intense  colicky  pains  in  the  abdomen,  but  either 
may  be  absent.  The  hemorrhage  may  be  concealed,  i.e,  the  blood 
dissecting  between  the  placenta  and  membranes  without  escaping 
from  the  womb,  or  in  small  quantity  only.  This  will  cause  dis- 
tention of  the  womb  and  pain.  The  amount  of  internal  hemor- 
rhage is  often  very  great.  The  condition  is  one  of  the  greatest 
gravity.  The  symptoms  of  concealed  hemorrhage  are  paleness 
of  the  face,  syncope,  thirst,  and  rapid,  weak  pulse  (120  to  130). 
The  uterus  will  be  found  enlarged  and  soft.  There  will  be  some 
bleeding  externally,  but  this  is  generally  slight  in  comparison  to 
the  amount  within  the  uterine  cavity.  Fetal  movements  are  weak 
or  absent  altogether. 

How  would  you  diagnosticate  partial  separation  of  the  placenta? 

If  the  separation  occurs  at  the  upper  part  of  the  placenta  (con- 
cealed hemorrhage),  the  main  diagnostic  symptoms  would  be  the 
sudden  anemia  and  shock,  abdominal  pain  and  rapid  increase  in  the 
size  of  the  uterus.  If  the  lower  part  is  detached  and  the  hemorrhage 
is  coming  away  (open  hemorrhage),  the  condition  may  simulate  pla- 
centa prasvia.  In  partial  detachment  no  placenta  can  be  felt  wholly 
or  partially  across  the  internal  os  and  the  attack  is  much  more  sudden 
than  is  placenta  previa  where  the  hemorrhage  usually  is  more  constant 
and  extends  over  a  longer  time. 

What  treatment  is  indicated? 

Prompt  delivery,  on  behalf  of  the  child,  which,  after  all,  is  usu- 
ally destroyed  by  the  impairment  or  total  stoppage  of  the  placental 
circulation;  and  also  on  account  of  the  mother,  if  the  hemorrhage 
is  at  all  extensive. 

1.  The  OS  uteri  should  be  dilated  sufficient^  to  allow  the  child  to 
pass. 

2.  The  membranes  should  be  ruptured,  and  the  child  at  once  de- 
livered by  forceps  or  version.  The  membranes  should  not  be 
ruptured  until  we  can  deliver,  for  the  evacuation  of  the  liquor 
amnii  gives  just  that  much  more  room  for  the  effusion  of  blood, 
without   any^gain   in   uterine   contraction.     Uterine   contraction 


PATHOLOGY  OF  PREGNANCY  69 

must  be  maintained  after  delivery  by  quinin,  ergot,  or  by  suita- 
ble packing  and  by  friction  for  some  time  afterward. 
3.  The  woman's  strength  must  be  maintained  by  hypodermics  of 
strychnin,  atropin,  and  ergotin,  or  by  whisky  and  hot  milk,  and 
inertia  guarded  against. 

Hypodermatoclysis,  or  the  subcutaneous  injection  of  a  sterile 
solution  of  sodiunf  chlorid,  5j  to  the  pint  of  sterilized  warm  water, 
should  be  used  to  maintain  the  fluids  of  the  body  and  keep  up  blood 
pressure.  If  symptoms  of  hemorrhage  are  severe,  the  salt  solution 
should  be  given  directly  into  a  vein  (intravenous  transfusion). 

Delivery  of  these  cases  by  celiohysterotomy  would  be  perfectly 
justifiable  if  the  patient  could  stand  the  operation.-  It  offers  by  far 
the  quickest  means  of  delivery.  Vaginal  Csesarean  section  has 
also  been  recommended.  For  either  of  these  operations  the  patient 
should  be  in  a  hospital. 

PLACENTA   PREVIA 

What  is  placenta  praevia? 

The  implantation  of  the  placenta  upon  the  lower  third  of  the 
uterine  wall;  to  the  part  which  dilates  during  labor  or  as  the  time  of 
labor  approaches.  The  placenta  may  be  centrally  placed  over  the 
OS  uteri;  its  margin  may  reach  to  the  edge  of  the  dilated  os;  or  any 
degree  between  these  extremes  may  be  met  with.  It  is,  therefore, 
divided  into  central,  partial,  and  marginal  placenta  praevia. 

How  and  why  does  placenta  praevia  occur? 

The  ovum  should  be,  and  usually  is,  arrested  as  soon  as  it  enters 
the  womb,  by  a  fold  of  the  mucous  membrane. 

If  these  folds  are  not  prominent  enough,  it  may  advance  until  it 
arrives  at  the  os  internum,  where  the  placenta  will  then  be  found. 
It  is,  therefore,  found  principally  in  multiparse,  and  in  those  whose 
organs  are  in  a  relaxed  condition. 

It  is  comparatively  rare  in  primipara  and  increases  in  frequency  ac- 
cording to  the  number  of  children  a  woman  has  borne.  As  causes  are 
given  multiple  pregnancies,  uterine  malformation,  changes  in  the 
uterine  mucosa,  diseases  of  the  endometrium,  etc. 

What  is  the  source  of  hemorrhage  in  placenta  praevia? 

The  blood  pours  from  the  openings  in  the  uterine  sinuses  when 
the  placenta  is  detached,  and  not  from  the  placenta  itself. 


70  COMPEND    OF    OBSTETRICS 

How  soon  does  placenta  praevia  cause  trouble,  and  in  what 
manner? 

Rarely  before  the  sixth  or  seventh  month  of  pregnancy. 

About  this  time  the  cervical  segment,  which  is  smaller  than  the 
fundal  region  of  the  womb,  has  nearly  reached  its  limits  of  growth. 
The  placenta  then  grows  faster  than  the  womb,  and  its  edge  is  liable 
to  become  detached.  Later  in  pregnancy  the  os  uteri  becomes 
patulous,  and  this  again  causes  some  separation  of  the  placenta. 
As  a  result,  hemorrhage  occurs,  more  or  less  profusely.  Usually, 
if  rest  is  enjoined,  the  opened  sinuses  are  closed  by  a  clot,  and  the 
hemorrhage  is  arrested  until  further  separation  takes  place. 

What  are  the  dangers  in  placenta  praevia? 

Death  of  the  mother  from  hemorrhage,  and  of  the  child  from 
asphyxia.  The  maternal  mortality  is  one  in  four;  fetal  mortality, 
one  in  two  or  three.  From  the  situation' of  the  placenta  and  the 
constant  separation  of  small  portions  of  it  leaving  absorbing  surfaces, 
infection  is  very  much  more  liable  to  occur  than  in  normal  cases  of 
pregnancy. 

What  treatment  is  demanded  when  it  occurs  before  full  term? 

Rest  in  bed,  with  or  without  a  tampon,  will  arrest  hemorrhage 
for  the  time;  the  sinuses  are  closed  by  thrombi,  and  the  case  may 
go  on  to  term  or  another  hemorrhage.  The  patient  should  be  al- 
lowed cold  drinks;  opium  may  be  used  where  pain  is  present.  If 
the  hemorrhage  is  great,  it  is  safer  to  induce  labor  at  once  than 
to  wait.  Occasionally  no  hemorrhage  occurs  during  pregnancy, 
nor  even  in  labor. 

How  should  delivery  be  managed  at  full  term? 

1.  The  patient  being  under  an  anesthetic  and  all  aseptic  precautions 
having  been  observed.  Introduce  one  or  two  fingers  within  the 
OS  (the  hand  being  in  the  vagina)  and  dissect  the  placenta  from 
the   uterine   wall  for  about  3  inches  from  the  os  uteri  in  all  di- 

-   rections,  pushing  it  to  one  side  if  necessary. 

2.  Rupture  the  membranes,  and  if  there  is  an  unfavorable  presen- 
tation, turn  the  child  and  make  the  breech  engage  in  the  os;  or, 
if  the  head  presents,  the  forceps  may  be  used,  if  speedy  delivery 
is  necessary.  The  uterus  shoiild  be  packed  with  aseptic  gauze  to 
prevent  secondary  hemorrhage.  This  is  the  conservative  treat- 
ment of  central  or  partial  placenta  prsevia. 


PATHOUOGY   OP   PREGNANCY  7 1 

The  strength  of  the  woman  is  then  the  main  point  to  be  cared 
for.  Tonic  doses  of  strychnin  and  ergot  should  be  given  by  hypodermic 
and  if  much  hemorrhage  has  occurred  the  patient  should  receive 
intravenous  injection  of  normal  salt  solution.  There  seems  to  be 
little  doubt  at  the  present  time  that  if  the  patient  is  in  a  hospital 
and  has  not  been  infected  by  much  handling,  delivery  by  either  va- 
ginal or  abdominal  Csesarean  section  offers  the  best  results  for  both 
mother  and  child.  There  is  much  less  danger  of  both  hemorrhage 
and  infection  for  the  mother  and  a  much  better  prognosis  for  the 
life  of  the  child. 

What  complications  may  interfere  with  rapid  delivery  through 
the  vagina? 

A  rigid  and  undilatable  cervix,  which  is  often  present,  because 
of  the  thickening  of  the  tissues  under  the  placental  insertion. 

How  is  this  to  be  overcome? 

In  premature  cases,  or  when  we  are  not  prepared  to  dilate,  the 
tampon  may  be  applied  for  some  hours.  Otherwise,  the  Moles- 
worth,  Barnes,  or  Bossi's  dilators  may  be  used  to  mechanically 
dilate  the  os,  if  the  fingers  cannot  do  it.  It  is  much  better  to  start 
the  dilatation  with  the  finger  and  when  sufficiently  dilated  insert  Barnes 
hydrostatic  bags.  Later  the  bag  of  Charpitier  de  Ribes  may  be  used. 
When  immediate  delivery  is  imperative,  the  cervix  should  be  divided 
by  the  "crucial"  incision  as  far  as  the  internal  os. 

What  is  a  tampon,  and  how  applied? 

A  tampon  is  a  plug  made  of  pieces  of  absorbent  cotton,  iodoform 
gauze,  strips  of  sterilized  muslin,  or  similar  materials,  packed  into 
the  vagina  so  as  to  restrain  hemorrhage. 

1.  Place  the  woman  in  Sims'  position,  and  introduce  a  Sims*  speculum. 

2.  With  a  pair  of  dressing  forceps  introduce  a  small  wad  of  ab- 
sorbent cotton  or  a  strip  of  gauze  within  the  os  uteri.  Continue 
to  add  similar  pieces  until  the  whole  upper  part  of  the  vagina  is 
packed  with  them. 

3.  Gradually  withdraw  the  speculum,  continuing  to  add  cotton  or 
gauze  until  the  whole  vagina  is  packed. 

4.  Apply  a  compress  and  T-bandage  over  the  vulva. 

How  long  should  a  tampon  be  left  in  place? 

Seldom  over  twelve  hours,  and  in  placenta  prasvia  it  may  be  neces- 
sary to  remove  it  within  an  hour  or  two. 


72  COMPEND    OF    OBSTETRICS 

What  effect  has  the  tampon  besides  restraining  hemorrhage? 

It  excites  uterine  contractions  and  aids  in  dilating  the  os.  This 
should  always  be  considered  where  these  results  are  not  desirable. 

What  cautions  are  to  be  observed  with  the  tampon? 

1.  The  tampons  should  be  of  iodoform  or  sterile  gauze.  If  this 
cannot  be  obtained  absorbent  cotton  may  be  used. 

2.  Never  introduce  it  when  the  membranes  have  been  ruptured, 
except  in  the  early  months  of  pregnancy,  lest  bleeding  occur  above 
it,  distending  the  uterus. 

3.  Care  should  be  taken  after  applying,  to  see  that  blood  does  not 
flow  past  or  through  it.     There  is  no  danger  if  it  is  properly  applied. 

What  treatment  should  be  used  after  delivery  in  placenta  praevia? 

In  cases  when  the  woman  has  been  delivered  by  vagina,  all 
lacerations  should  be  repaired.  Strychnin,  digitalin  (if  needed) 
atropin  and  sterile  ergot  should  be  used  hypodermatically.  Saline 
solutions  should  be  given  intravenously  if  needed.  The  uterus  and 
vagina  should  be  packed  with  aseptic  gauze  and  the  vulva  covered 
by  a  sterile  pad. 

When  the  patient  has  been  delivered  by  a  vaginal  or  abdominal 
Caesarean  section  the  treatment  is  the  same  as  after  the  same  operation 
for  an}^  other  cause  (see  these  subjects). 

What  complications  may  occur  in  placenta  praevia  after  delivery? 

The  exposed  sinuses  in  the  cervical  region  may  not  be  efficiently 
sealed,  and  hemorrhage  may  continue.  The  management  will  be  as 
in  post-partum  hemorrhages  generally. 

What  is  a  fetus  papyraceus? 

A  twin  dying  in  utero  at  an  early  period  may  be  partly  desiccated, 
and  compressed  by  the  growth  of  the  other  twin,  being  flattened  and 
parchment-like  in  appearance. 

What  is  a  lithopaedion? 

A  dead  child  may  be  infiltrated  and  encrusted  by  calcareous  salts 
until  it  is  stone-like  in  appearance.  This  occurs  only  after  long 
retention  in  extra-uterine  cysts. 

ECTOPIC  OR  EXTRAUTERINE  PREGNANCY 

What  is  extra -uterine  pregnancy? 

Pregnancy  in  which  the  fetus  is  developed  in  some  other  locality 
than  in  the  uterus. 


PATHOLOGY  OF  PREGNANCY  73 

What  are  some  of  the  causes  of  ectopic  pregnancy? 

Broadly  speaking,  it  may  be  produced  by  any  condition  which 
prevents  or  renders  difficult  the  passage  of  the  ovule  to  the  uterus, 
but  which  at  the-  same  time  is  not  sufficient  to  keep  the  ovule  from 
being  impregnated  by  the  spermatozoa.  The  most  common  causes 
are  old  inflammations  which  have  destroyed  the  cilia  of  the  tubes, 
or  small  polypoid  growths  obstructing  their  lumen.  They  also 
appear  in  old  primiparae  and  in  those  who  have  been  previously  sterile. 
Fright  during  coition  has  also  been  given  as  a  cause. 

How  is  ectopic  pregnancy  classified? 

1.  The  ovum,  after  fecundation,  may  remain  in  the  ovisac  and  be 
developed  in  the  ovary,  called  ovarian  pregnancy. 

2.  The  fecundated  ovum  may  be  arrested  in  the  Fallopian  tube, 
and  be  there  developed,  called  tubal  pregnancy.  This  is  the  most 
common  form. 

3.  It  may  be  arrested  at  the  junction  of  a  tube  and  the  uterus  (the 
narrowest  part),  and  be  developed  partly  in  the  womb  and  partly 
in  the  tube,  called  tuh.o-uterine  or  iterstitial  pregnancy. 

4.  It  may  drop  from  the  ovary  into  the  abdominal  cavity,  and  be 
there  developed,  called  abdominal  pregnancy. 

5.  The  ovum  may  develop  in  one  horn  of  a  bicornate  uterus. 

6.  It  is  also  possible  for  the  impregnated  ovum  to  develop  up  to  a 
certain  stage  in  a  hernial  sac. 

Are  ovarian  and  abdominal  pregnancies  common? 

Ovarian  pregnancies  are  rare  but  do  occur.  Primary  abdominal 
pregnancies  are  doubtful  but  attachments  of  the  ovum  to  abdominal 
organs  or  to  the  broad  ligament  (secondary  abdominal  pregnancies) , 
following  rupture  of  an  ectopic  tubal  pregnancy  do  occur  and  the 
fetus  may  be  developed  then  if  the  patient  survives  the  hemorrhage 
and  shock  of  the  tubal  rupture. 

What  is  the  pathology  of  ectopic  pregnancy? 

The  gestation  sac  is  formed  in  tubal  pregnancy  from  the  coats  of 
the  wall  of  the  tube,  and  the  muscular  tissue  instead  of  undergoing  hy- 
pertrophy often  tends  to  disappear.  Slight  peritonitis  sometimes  ap- 
pears and  adhesion  may  form.  The  attachment  of  the  ovum  does  not 
differ  radically  from  that  of  normal  uterine  pregnancy.  A  placenta 
forms  but  the  decidual  structures  are  rudimentary,  so  that  the  chorionic 
villi  penetrate  into  the  gestation  sac  as  far  as  the  peritoneum.     This 


74  COMPEND    OF    OBSTETRICS 

phenomenon  by  favoring  hemorrhage  tends  to  favor  both  abortion  and 
rupture.  The  ovum  may  undergo  early  death  in  the  tube  and  form  a 
mole,  or  if  rupture  of  the  tube  occurs  the  ovum  expelled  into  the  ab- 
dominal cavity  usually  perishes  and  if  very  young  may  be  absorbed. 
In  very  exceptional  cases  it  may  thrive  (secondary  abdominal  preg- 
nancy) .  If  the  ovum  escapes  into  the  broad  ligament  death  with  molar 
formation  may  result,  sometimes  from  suppuration.  If  the  fetus  dies 
after  reaching  an  advanced  stage  of  development  calcification,  adipo- 
ceration  or  mummification  may  result.  The  sac  in  this  condition 
may  remain  quiet  for  years  and  afterward  rupture  into  a  viscus  or 
cavity. 

If  the  fetus  does  not  die  its  tendency  is  toward  poor  nutrition  and 
development  and  is  frequently  followed  by  fetal  disease  and  deform- 
ities. If  it  reaches  a  viable  age  it  frequently  dies  during  its  extrac- 
tion or  soon  after.     Exceptionally  it  is  well  developed  and  survives. 

The  changes  in  the  uterus  are  much  the  same  up  to  a  certain  point 
as  those  found  in  intrauterine  pregnancy  even  the  formation  of  the 
decidua  vera.  If  the  ovum  dies  these  changes  are  arrested,  otherwise 
they  progress  although  at  a  slower  rate  than  in  an  intrauterine  preg- 
nancy (after  Edgar). 

What  effect  has  extrauterine  pregnancy  on  the  womb? 

It  enlarges  as  in  normal  pregnancy,  up  to  the  fifth  month,  and  its 
hypertrophied  mucous  membrane  or  decidua  is  cast  off  in  one  piece, 
in  several  pieces,  or  in  flaky  shreds,  at  from  the  second  to  the  fifth 
month. 

What  are  the  symtoms  of  extrauterine  pregnancy? 

Symptoms  before  rupture. 

1.  The  symptoms  of  pregnancy  in  general. 

2.  The  presence  of  a  cystic  tumor  in  the  abdomen,  usuaUy  to  be  felt 
also  in  Douglas'  cul-de-sac. 

3.  The  enlargement  of  the  womb,  and 

4.  The  displacement  of  the  womb  by  the  tumor. 

5.  Irregular,  sanguineous  discharges  from  the  womb. 

6.  The  expulsion  of  the  enlarged  uterine  mucous  membrane  (decidua). 

7.  Pain,  irregular  in  occurrence,  and  of  intense  character. 

When  rupture  of  the  gestation  sac  occurs,  symptoms  of  rapidly  de- 
veloping shock  and  internal  hemorrhage.  When  the  rupture  occurs 
between  the  folds  of  the  broad  ligament  the  danger  of  fatal  hemorrhage 
and  shock  are  much  less  than  when  rupture  takes  place  at  the  upper 


PATHOLOGY    OF   PREGNANCY 


75 


or  lower  part  of    the   broad   ligament, 
causes  extreme  pain  from  distention. 


The    hematoma    however 


What  points  are  especially  important  in  diagnosis? 

A  rapidly  growing  tumor  in  Douglas*  cul  de  sac,  with  an  enlarged 
but  empty  womb,  from  which  portions  of  decidual  membrane  have 
passed,  can  be  nothing  else  than  an  extra-uterine  cyst.  The  pain 
if  present,  is  characteristic.  Abdominal  pregnancy  may  proceed  to 
term  without  exciting  any  suspicions  of  its  presence. 

With  what  other  conditions  may  extra-uterine  pregnancy  be 
confounded? 

1.  Intra-uterine  pregnancy  complicated  with  a  fibroid  tumor. 

2.  Intra-uterine  pregnancy  cornplicated  with  pyosalpinx. 

3.  Intra-uterine  pregnancy  with  lateral  flexion  of  the  uterus. 


How   would   you    differentiate    extra-uterine    (tubal)    pregnancy 
from  intra-uterine  pregnancy  complicated  with  a  fibroid  tumor? 


Tubal  Pregnancy. 


Intra-uterine    Pregnancy 
WITH   Fibroid   Tumor. 


The  uterus  is  enlarged,  but  not 
to  a  size  proportionate  to  the 
period  of  gestation. 

On  one  side  of  the  uterus  will 
be  found  a  rounded,  highly 
sensitive,  elastic  or  fluctuat- 
ing mass. 

There  is  a  history  of  irregular 
menstruation.     Menstruation 
may  partially  return  early. 

Rupture  of  the  gestation  sac 
occurs. 

Pain  is  an  early  and  a  promi- 
nent symptom. 


The  size  of  the  uterus  corre- 
sponds to  or  even  exceeds 
that  of  an  uncomplicated  ges- 
tation. 

The  mass  is  uaually  nodulated, 
hard,  non-elastic,  without 
fluctuation,  and  is  not  sensi- 
tive to  touch. 

Usually  there  is  suppression  of 
menstruation. 

No  rupture. 

Pain  develops  only  after  the 
tumor  has  reached  sufficient 
size  to  press  on  the  surround- 
ing tissues. 


76 


COMPEND    OF    OBSTETRICS 


How   would   you   differentiate    extra-uterine   pregnancy   from   pyo- 

salpinx? 


Extra-uterine  Pregnancy. 

The  body  of  the  uterus  is  en- 
larged and  softened.  Cervix  is 
soft  and  velvety. 

The  tumor  is  small,  very  sen- 
sitive, and  usually  not  bound 
down  in  the  pelvic  cavity. 

Rupture  usually  takes  place 
about  the  third  month. 

Usually  some  history  of  sterility, 
with  endometritis  or  salpingitis. 

Usual  symptoms  and  physical 
signs  of  pregnancy  present. 


Pyosalpinx. 

Uterine  body  not  enlarged;  no 
softening  of  the  cervix. 

The  tumor  is  large,  somewhat 
sensitive,  firmly  bound  down 
in  the  pelvis,  and  is  sur- 
rounded by  a  mass  of  lymph. 

The  condition  is  subacute  or 
chronic,  and  may  extend  over 
months.     Xo  rupture  occurs. 

There  is  a  history  of  acute 
attacks  of  peritonitis  occur- 
ring at  intervals. 

Usual  symptoms  of  pregnancy 
absent.- 


How    would    you    diagnosticate    extra-uterine    from    intra-uterine 
pregnancy  with,  lateral  flexion  of  the  uterus? 


Extra-uterine 


Pregnancy. 


The  body  and  cervix  of  the  en- 
larged uterus  are  generally 
in  a  straight,  vertical  line. 

The  extra-uterine   gestation   sac 

'  is  in  close  proximity  to  the 
body  of  the  uterus. 

The  mass  is  closely  attached 
to  the  fundus,  and  is  re'adil}^ 
outlined. 

The  size  of  the  uterus  is  below 
that  indicated  by  the  dura- 
tion of  pregnancy. 

Menstrual  history  irregular. 

Severe  pain  and  rectal  tenesmus. 


Intra-uterine  Pregnancy 
with  Lateral  Flexion  of 
the   Uterus    (Borland). 

The  fundus  lies  to  one  side  of 
the  pelvis,  with  the  cervix 
carried  to  the  opposite  side. 

A  deep  sulcus  may  be  felt  be- 
tween the  fundus  and  the 
cervix. 

Examination  shows  a  normal 
condition  of  the  appendages. 

Size  of  the  uterus  corresponds 
to  the  period  of  gestation. 

Menstruation  is  suppressed. 
Usually     no     pain;     no     rectal 
tenesmus. 


PATHOLOGY  OP  PREGNANCY  77 

What  is  the  termination  of  extra-uterine  pregnancy? 

1.  Rup'ture  of  the  cyst  occurs  in  35  per  cent.,  followed  by  internal" 
hemorrhage,  shock,  peritonitis,  and  usually  death. 

2.  The  pregnancy  may  continue  until  full  term,  the  child  dies  and 
(a)  the  tumor  is  partially  reabsorbed,  and  remains  innocuous, 
or  (b)  inflammation  supervenes,  and  the  child  is  decomposed 
and  evacuated  by  ulcertaion  into  the  rectum,  vagina,  bladder, 
abdominal  walls,  or  uterus — the^  woman  running  the  gauntlet  of 
peritonitis,  septicemia,  pyemia,  etc. 

When  does  the  rupture  of  the  cyst  occur? 

In  the  first  half  of  pregnancy;  seldom  in  second  half;  usually 
about  the  third  month. 

What  is  the  treatment  for  ectopic  pregnancy? 

If  sure  of  the  diagnosis,  open  the  abdomen  by  an  incision,  ligate 
bleeding  vessels,  and  remove  all  blood  and  fluids. 

What  is  the  general  treatment  of  extra-uterine  pregnancy? 

Practically  the  only  method  of  treating  ectopic  pregnancy  is  by 
operation. 

If  the  condition  is  diagnosticated  early  or  a  pregnant  tube  found 
during  operation  for  another  cause  it  should  be  removed  and_^  the 
ovary  unless  involved  or  diseased  let  alone. 

After  rupture  always  operate;  the  ruptured  tube  should  be  found, 
tied  off  and  removed,  the  abdomen  sponged  out,  all  blood  removed  and 
closed.  If  the  patient  should  show  the  effects  of  severe  hemorrhage 
and  shock,  stimulate  and  salt  solution  should  be  used  intravenously.  If 
one  is  sure  that  rupture  has  occurred  between  the  folds  of  the  broad 
ligament  and  a  hsematoma  is  formed  it  may  be  let  alone  for  a  while  or 
drained  through  the  posterior  cul-de-sac  or  removed  by  section  later. 
If  tubal  abortion  has  occurred,  operation  should  be  done,  escaped  blood 
clots,  fetal  tissue,  etc.,  removed  by  sponging  and  the  ruptured  tube 
removed.     The  fetal  sac  should  be  extirpated. 

If  rupture  occurs  after  the  formation  of  the  placenta,  the  sac  should 
be  opened,  the  fetus  removed,  the  cord  tied  close  to  the  placenta  and 
the  edges  of  the  incision  should  be  stitched  to  the  external  wound 
the  sac  being  packed  with  gauze  after  careful  cleansing  with  salt 
solution.  The  gauze  may  be  removed  in  forty-eight  hours  or  a  glass 
drain  may  be  used  after  the  first  packing  is  removed.  This  lessens 
the  danger  of  hemorrhage  and  allows  the  placental  circulation  to 
cease.     The  placenta  will  then  come  away  in  pieces. 


78 


COMPEND    OF    OBSTETRICS 


Sptrri^, 


Fig,  37.— Pregnancy  in  the  Rxjdimentary  Horn  of  a  Uterus  Unicornis. 
The  rudimentary  horn  is  shut  off  from  the   uterine  cavity.     The  corpus  luteum 
was  found  in  the  ovary  of  the  opposite  side;  hence  intraperitoneal  transmigration 
of  the  ovum  occurred. — (Howard  Kelly.) 


Fig.  38. — Uterus  Duplex  Bicornis,  with  a  Vaginal  Septa. 
The  right  uterus  contained  the  product  of  conception  and  „was  6  3/4  inches  (17 
cm.)  long;  the  left  uterus  was  filled  with  decidua  alone  and  was  4  3/4  inches  (12 
cm.)  long,     r,  Right  uterus;  v,  right  vagina;  i,  intervaginal  septum. — {Nagel.*) 


PATHOLOGY  OF  PREGNANCY  79 

What  is  cornual  pregnancy? 

Corriual  pregnancy  is  the  development  of  an  ovum  in  one  horn  of  a 
bicornute '  uterus  or  in  one  side  of  a  '^double  uterus.  If  the  horn 
is  well  developed,  delivery  may  be  normal  but  if  the  horn  is  rudi- 
mentary and  there  is  no  normal  communication  with  the  lower  genital 
tract  the  resulting  condition  is  very  much  like  extra-uterine  piegnancy. 
The  symptoms  are  much  like  those  of  ectopic  pregnancy.  When 
the  pregnant  horn  is  nearly  normal  in  size  or  in  a  double  uterus 
the  pregnant  tumor  will  be  found  more  unilateral  than  normal 
and  in  some  cases  the  empty  horn  or  uterus  can  be  demonstrated. 
The  treatment  is  usually  delivery  by  abdominal  section. 

What  do  we  understand  by  missed  labor? 

It  is  a  condition  in  which  the  fetus  is  retained  in  the  uterus  for 
any  length  of  time  beyond  term.  Usually  some  of  the  earlier  symp- 
toms of  true  labor  come  on,  but  do  not  continue.  The  fetus  gen- 
erally dies. 

VARICOSE  VEINS 

What  is  the  treatment  of  varicose  veins  of  the  lower  limbs? 

Rest  in  the  recumbent  posture,  with  regulation  of  the  bowels. 
The  leg  should  be  elevated  and  an  elastic  stocking  or  flannel  bandage 
applied;  care  must  be  taken  not  to  apply  too  tightly. 

What  is  the  treatment  for  varicose  veins  of  the  vulva? 

As  much  rest  in  bed  as  possible.  An  abdominal  binder  may  be 
of  some  service.  The  bowels  shoud  be  kept  open,  preferably  by 
salines. 

What  is  the  treatment  of  rupture  of  a  vein? 

A  compress  should  be  applied  over  the  point  of  rupture  and  a- 
firm  bandage  applied,  or  a  needle  may  be  passed  under  the  bleedr 
ing  vein  and  a  figure-of-8  ligature  carried  around  it.  In  severe 
cases  it  may  be  necessary  to  cut  down  on  the  vein  and  ligate  it. 
In  some  instances  rupture  of  a  vein  below  the  skin  may  produce  a 
haematoma  of  considerable  size.  Rest  and  cold  evaporating  lotions 
are  the  proper  treatment. 

What  are  salivation,  chloasma,  hirsuties? 

(a)  Salivation  is  an  increased  flow  of  saliva,  usually  found  only 
in  the  latter  half  of  pregnancy,  and  often  accompanied  by  ulcerations 
in  the  mouth. 

ih)  Chloasma  is  an  excessive  deposit  of  pigment  in  the  skin.  Though 
6 


8o  COMPEND    OF    OBSTETRICS 

usually  confined  to  the  mammary  areolae  and  the  brown  line,  it 

may  occur  on  the  face,  the  entire   abdomen,    and  flexures  of  the 

joints,'^suggesting^ Addison's  disease. 
(c)  Hirsuties  is^an  excessive  or  abnormal  growth  of  hair,   usually 

on  the  face,  and  fortunately  rare. 

The  treatment  of  these  conditions  is  the  same  in  the  pregnant  as 
in  the  non-pregnant  state. 

DISEASES  OF  THE  ORGANS  OF  GENERATION 

What  is  pruritus  vulvae? 

An  itching  of  the  external  genital  organs. 

What  are  its  causes? 

It  may  be  caused  by  any  irritative  discharge  from  the  vagina, 
due  to  malignant  disease  of  the  uterus,  erosion  of  the  cervix,  cervical 
catarrh,  etc.  Diabetes  may  cause  it,  and  also  various  local  con- 
ditions of  the  vulva,  as  edema,  eczema,  herpes,  follicular  inflamma- 
tion, or  prurigo.  Menstruation  and  pregnancy,  by  producing  a  con- 
gestion of  the  genitals,  may  produce  a  pruritus.  Generally  in 
pruritus  vulvae,  occurring  during  pregnancy,  there  is  no  visible  lesion 
of  the  parts. 

How  is  pruritus  vulvae  treated? 

Treat  the  cause  when  possible.  Strict  cleanliness  must  be  ob- 
served. The  patient  should  wash  the  parts  with  any  of  the  follow- 
ing: Lead- water  and  laudanum,  applied  hot,  or  a  2  to  3  per  cent, 
solution  of  carbolic  acid,  or  hyposulphite  of  soda  gss  to  Oj  of  hot 
water.  These  may  be  followed  by  dusting  the  parts  with  a  powder 
of  equal  parts  calomel  and  bismuth.  Nitrate  of  silver,  gr.  viij  to 
xij  to  §j,  or  beta-naphthol  bismuth  and  sulphur  ointment,  may  be 
used.  An  ointment  of  chloral  hydrate  and  camphor,  aa  §ss,  is  some- 
times of  use.  Aquae  rosae  has  also  been  recommended.  Warm  bran 
sitz  baths  have  been  used  with  benefit. 

How  are  vegetations  of  the  vulva  treated? 

No  active  treatment  is  advisable,  unless  they  become  very  large, 
as  they  disappear  at  the  end  of  pregnancy;  if  removed,  they  are 
very  liable  to  return.  The  surfaces  should  be  kept  apart  and  com- 
presses saturated  in  a  solution  of  carbolic  acid,  or  Labarraque's 
solution,  applied. 

What  is  the  treatment  of  leucorrhea . 

If  the  discharge  be  slight,  use  tepid  astringent  injections:  alum, 


PATHOLOGY    OF    PREGNANCY  8 1 

borax,    sulphate   of   zinc,    carbolic   acid,    chlorate   of  potassium,   or 
common  salt. 

If  the  secretions  are  excessive  and  cause  irritation  of  the  gen- 
itals, the  use  of  the  cotton  tampon  is  the  best  treatment.  Take  a 
dry  tampon  of  cotton  and  enclose  in  it  either  boracic  acid,  alum, 
or  the  subnitrat§  of  bismuth.  Then  introduce  into  the  vagina  and 
allow  it  to  remain  for  twelve  or  twenty-four  hours;  after  its  re- 
moval use  a  tepid  astringent  injection.  A  tampon  saturated  with 
glycerin  containing  either  boracic  acid  or  tannin  may  be  used  in 
the  place  of  the  dry  tampon.  A  new  tampon  should  be  introduced 
into  the  vagina  every  day  for  three  or  four  days.  If  the  leucor- 
rhoea  be  specific  in  origin,  apply  to  the  vagina,  either  a  solution  of 
corrosive  sublimate,  i  part  to  looo,  or  nitrate  of  silver,  30  to  60 
grains  to  the  ounce. 

What  is  the  indication  for  treatment  in  prolapse  of  the  uterus? 

To  reduce  the  prolapse:  The  patient  should  assume  a  recumbent 
position  as  often  as  possible  and  wear  a  pessary;  in  most  cases  the 
prolapse  is  spontaneously  cured  about  the  fourth  month.  In  cases 
where  a  pessary  cannot  be  worn,  support  the  uterus  with  a  cotton 
tampon.  If  the  uterus  protrudes  externally  and  cannot  be  restored 
to  its  normal  position,  then  a  bandage  must  be  applied  to  support  it. 

A  pessary  may  be  worn  until  the  sixth  month;  the  best  instru- 
ment to  use  is  Hodge's  pessary. 

After  labor  the  patient  should  have  a  prolonged  rest  in  bed  and  the 
prolapse  should  be  permanently  cured  by  some  operative  procedure. 

Are  anterior  displacements  of  the  uterus  considered  of  impor- 
tance during  pregnancy? 

No;  they  are  seldom  sufficiently  marked  to  be  pathological.  In 
the  multigravida,  the  uterus  is  always  more  or  less  anteverted,  on 
account  of  the  relaxation  of  the  abdominal  muscles.  If  the  ante- 
version  is  moderate,  no  symptoms  are  produced;  but  if  it  is  marked, 
there  are  constipation,  tenesmus,  pains  in  the  lumbar  and  sacral 
region,  and  irritability  of  the  bladder.  Nausea  and  vomiting  may 
occur. 

What  is  the  treatment  of  anteversion? 

The  bowels  should  be  regulated,  and  the  patient  kept  in  a  re- 
cumbent position.  The  uterus  may  be  supported  by  the  open  cup- 
pessary  of  Thomas,  or  a  horseshoe  tampon  of  lambs'  wool. 


82  COMPEND    OF    OBSTETRICS 

In  the  latter  months  of  pregnancy  an  abdominal  bandage  must 
be  firmly  applied  to  support  the  uterus. 

Is  retroversion  of  the  uterus  a  frequent  complication  of  pregnancy? 

No;  it  is  infrequent  in  the  impregnated  uterus. 

What  are  the  results  of  retroversion? 

1.  It  spontaneously  rises  into  the  abdominal  cavity. 

2.  It  remains  below  the  promontory  of  the  sacrum,  and  the  cervix 
bending  upon  itself,  it  becomes  a  retroflexion. 

What  are  the  results  of  retroflexion? 

1.  It  usually  rises  into  the  abdominal  cavity  and  the  pregnancy 
may  continue  to  term. 

2.  Abortion  may  occur,  the  result  of  inflammation  of  the  uterus. 

3.  The  uterus  may  become  incarcerated  below  the  promontory  of 
the  sacrum. 

What  is  the  treatment  of  retroflexion? 

If  the  uterus  is  movable,  it  should  be  replaced  and  a  pessary  worn 
until  the  fourth  month.  The  Albert  Smith  or  Hodge  pessary  will  be 
found  most  useful.  The  bowels  should  be  kept  regular,  and  urine 
should  not  be  allowed  to  accumulate  in  the  bladder;  there  should  be 
no  compression  around  the  abdomen,  and  straining  at  stool  should 
be  avoided.  The  patient  should  assume  the  knee-chest  position  for 
a  few  minutes  every  day,  and  when  lying  in  bed  should  not  be  upon 
her  back,  but  upon  her  side.  If  the  uterus  is  immovable,  gradual 
attempts  to  restore  it  should  be  made  daily,  as  follows: 

1.  The  patient  assumes  the  knee-chest  position,  and  the  physician 
introduces  two  fingers,  either  into  the  rectum  or  vagina,  and 
makes  gentle  pressure  upon  the  fundus  of  the  uterus;  the  uterus 
may  be  gradually  restored  in  about  a  week  or  longer. 

2.  Press  the  body  of  the  uterus  up  with  the  blade  of  a  Sims'  specu- 
lum, and  at  the  same  time  catch  the  cervix  with  a  tenaculum  and 
draw  it  downward  and  backward. 

After  the  uterus  has  been  restored  to  its  normal  position  a  pessary 
should  be  worn. 

3.  If  this  does  not  succeed  the  cervix  should  be  grasped  with  a  ten- 
aculum or  vulsellum  forceps  and  the  uterus  drawn  down  sufficiently 
to  clear  the  promontory.  Two  fingers  in  the  posterior  cul-de-sac 
should  then  press  the  fundus  forward.  This  manipulation  is  usually 
successful    especially  if  the  patient  is  under    an    anesthetic.     If 


PATHOLOGY  OF  PREGNANCY  83 

adhesions  exist  binding  the  uterus  posteriorly  it  may  be  better  to 
replace  the  uterus  following  abdominal  section  and  the  breaking 
up  of  adhesions.  Abortion  is  most  apt  to  occur.  If  the  uterus 
is  adherent  in  retroposition  the  patient  usually  aborts  and  at  the 
same  result  not  infrequently  follows  attempts  at  replacement  when 
adhesions  occur.  These  patients  should  be  attended  in  a  hospital 
and  for  the  physician's  safety  he  had  better  have  a  consultation. 

•    What  are  the  symptoms  of  incarceration? 

Retention  of  urine,  in  some  cases  associated  with  incontinence;  or 
frequent  inadequate  and  painful  micturition ;  difficult  and  painful  defe- 
cation; constipation;  severe  pains  in  the  lumbar  and  sacral  regions;  a 
heavy  bearing-down  sensation  in  the  pelvis;  pain  down  the  thighs; 
and,  in  some  cases,  oedema  of  the  legs  and  feet.  If  the  incarceration 
is  not  relieved,  peritonitis  and  uraemia  follow. 

What  are  the  results  of  incarceration? 

1.  Spontaneous  restitution. 

2.  Abortion  and  recovery. 

3.  Cystitis;  retention  of  urine. 

4.  Inability  to  empty  the  bowels. 

5.  Death  from: 

(a)  Metritis. 

(&)  Perforation  of  the  bladder. 

(c)  Gangrene  of  the  uterus. 

(d)  Ursemia, 

(e)  Peritonitis. 

What  is  the  treatment  of  incarceration? 

The  indication  is  to  replace  the  uterus.  The  bladder  and  bowels 
should  be  evacuated,  the  former  with  a  catheter;  if  this  is  found 
to  be  impossible,  then  aspirate  about  3  inches  above  the  pubes. 
In  a  number  of  cases  spontaneous  restitution  occurs  after  the  bladder 
is  emptied;  if  this  does  not  occur,  then  the  uterus  must  be  replaced. 
If  the  uterus  is  bound  down  by  adhesions  and  cannot  be  restored, 
then  abortion  must  be  induced.  If  the  cervix  cannot  be  reached 
for  this  purpose,  the  uterine  wall  must  be  punctured  through  the 
vaginal  vault  in  order  to  drain  off  the  liquor  amnii.  It  may  then  be 
possible  to  draw  down  the  cervix  and  empty  the  uterus. 

To  restore  the  uterus  place  the  patient  in  the  knee-chest  position 
and  make  steady  pressure  upon  the  fundus  with  two  fingers  either 


84  COMPEND    OF    OBSTETRICS 

in  the  vagina  or  rectum.  In  cases  requiring  the  use  of  an  anaes- 
thetic, place  the  patient  in  Sims'  latero-prone  position  and  make 
pressure  upon  the  fundus  of  the  uterus  by  means  of  four  fingers 
introduced  into  either  the  vagina  or  rectum.  Playfair,  in  cases  of 
incarceration,  advises  the  use  of  a  rubber  bag  introduced  into  the 
vagina  and  filled  with  water;  the  water  must  be  let  out  every  few 
hours  to  allow  the  woman  to  empty  the  bladder.  Generally  the 
uterus  is  replaced  in  twenty-four  hours  by  this  method. 

After  the  uterus  has  ben  replaced,  the  patient  should  wear  a 
pessary.  A  relapse  is  not  likely  to  occui.  In  very  severe  cases 
vaginal  hysterectomy  may  have  to  be  performed. 

What  are  the  causes  of  prolapse  of  the  pregnant  uterus? 

This  condition  occurs  only  in  the  early  months  of  pregnancy,  as  the 
result  of  traumatism  or  violent  straining,  or  when  the  vaginal  outlet 
is  greatly  relaxed  or  torn. 

What  is  the  treatment? 

This  consists  in  replacing  the  uterus  and  fitting  a  proper  pessary  or 
large  wool  tampon. 

CONSTIPATION,  DIARRHEA,  INDIGESTION 

What  is  the  treatment  of  constipation  during  pregnancy? 

Regulation  of  the  diet;  as  a  rule  too  much  meat  is  to  be  avoided; 
fresh  fruits,  bread,  and  the  grain  foods  arc  beneficial.  Active  purga- 
tion is  to  be  avoided,  as  is  also  the  continued  use  of  any  strong  purga- 
tive drugs.  The  use  of  enteroclysis  of  2  to  4  quarts  of  normal  saline 
solution  is  to  be  recommended.  It  may  be  repeated  about  three  times 
a  week.  Agents  such  as  cascara,  small  doses  of  calomel,  sulphate  of 
magnesia,  or  the  compound  colocynth  pill  will  do  good.  Diarrhea  in 
pregnancy  is  rare;  when  it  occurs,  the  cause  should  be  sought  for  and 
treated.  Indigestion — gastric  or  intestinal — should  be  treated  by 
regulating  the  diet  and  administering  such  drugs  as  are  ordinarily 
used.  It  must  not  be  forgotten  that  persistent  indigestion  is  often  a 
symptom  of  the  toxemia  of  pregnancy. 

What  are  the  causes  of  jaundice  in  pregnancy? 

It  may  result  from  gastro-intestinal  catarrh,  toxemia,  phosphorus 
poisoning,  obstruction  of  the  bile  duct  due  to  calculi  in  the  gall- 
bladder, pressure  by  the  uterus,  or  from  acute  yellow  atrophy  of  the 
liver.  It  is  often  a  source  of  grave  danger  to  the  fetus,  and  may  pro- 
duce abortion  in  the  mother. 


PATHOLOGY    OF    PREGNANCY  85 

What  is  the  treatment? 

Regulation  of  the  diet,  warm  alkaline  douches,  and  calomel.  In 
severe  cases  abortion  may  have  to  be  induced.  Calculi  may  require 
operation  as  in  any  other  condition. 

How  is  difficulty  in  urination  caused? 

During  ■  the  first  months  the  descent  and  anteversion  of  the 
uterus  may  cause  pressure  on  the  bladder.  After  the  womb  has 
ascended  above  the  pelvic  brim,  there  is  rarely  any  difficulty  until  its 
descent,  during  the  last  week,  when  pressure  is  again  caused. 

How  are  the  albuminuria  and  edema  caused? 

Small  quantities  of  albumin  may  be  found  in  the  urine  of  pregnant 
women  and  may  be  due  to  the  increased  pressure  in  the  renal  circula- 
tion. The  albumin  in  the  urine  is  not  accompanied  by  tube  casts. 
It  is  a  safe  rule  to  go  by  that  when  casts  and  albumin  exist  for  any 
length  of  time  it  is  a  danger  signal. 

Nephritis  may  coexist  or  originate  with  the  pregnancy.  It  is  a 
serious  complication  of  the  pregnant  state  and  always  renders  the 
prognosis  for  both  mother  and  child  doubtful. 

Edema,  usually  limited  to  the  lower  extremities  and  vulva,  may  be 
consequent  upon  renal  disease  or  due  to  pressure  upon  the  abdominal 
and  pelvic  venous  trunks. 

What  is  the  treatment  of  nephritis  in  pregnancy? 

Frequent  examinations  of  the  urine  should  be  made.  Meat 
must  be  excluded  from  the  diet,  and  milk  or  foods  containing  milk 
substituted.  The  bowels  must  be  kept  open  by  calomel  and  salines, 
and  the  quantity  of  urine  increased  by  diuretics.  For  diaphoresis, 
sweet  spirits  of  niter,  infusion  of  digitalis,  Basham's  mixture,  and 
the  hot  pack  may  be  employed.  An  examination  of  the  eyes  should 
always  be  made  to  determine  the  presence  of  albuminuric  retinitis, 
and  if  that  condition  is  found,  abortion  must  be  performed  at  once. 
The  symptoms  are  the  same  as  in  nephritis  at  any  other  time. 

How  are  constipation  and  hemorrhoids  caused? 

Constipation  may  be  due  to  the  deteriorated  (hydremic)  state  of  the 
blood,  but  it  is  also  due  to  direct  pressure  of  the  uterus  upon  the 
bowel,  impairing  its  tonicity,  or  even  acting  mechanically.  Hemor- 
rhoids are  caused  in  the  same  way. 

How  is  dyspnea  caused? 

By  pressure  upon  the  diaphragm.  ,  It  therefore  appears  late  iij 


86  COMPEND    OF    OBSTETRICS 

pregnancy,  and  is  usually  relieved  during  the  last  weeks  by  the  descent 
of  the  uterus. 

What  is  the  prognosis  of  pulmonary  tuberculosis  in  pregnancy? 

Most  unfavorable.  The  patient  may  seem  to  improve  during  early 
piegnancy,  but  the  disease  makes  rapid  advances  after  delivery. 
The  effect  of  the  pregnancy  upon  a  tuberculous  patiert  should  be 
watched  carefully  and  if  her  strength  should  fail  the  uterus  should 
be  promptly  emptied  and  the  piegnancy  terminated. 

What  is  meant  by  plethora  in  pregnancy? 

The  natural  increase  in  the  blood-making  function  is  occasion- 
ally excessive,  and  too  much  blood  is  furnished,  leading  to  attacks  of 
vertigo  and  other  symptoms  of  that  condition. 

What  effect  has  pregnancy  on  diseases  of  the  heart? 

Unfavorable.  Pregnancy  increases  the  danger  of  heart  lesions. 
Abortion  is  apt  to  occur.  Complications  to  be  dreaded  are  failure  of 
compensation,  due  to  overtaxing  of  the  heart  or  to  fatty  degeneration, 
and  pulmonary  congestion. 

What  forms  of  neuralgia  are  met  with  in  pregnancy? 

Almost  any  form.  The  most  common  is  odontalgia.  Toothache 
is  due  (i)  to  the  "cry  of  the  nerve  for  healthy  blood,"  and  (2)  to  the 
fact  that  phosphate  of  lime  is  largely  needed  in  the  construction  of  the 
fetus,  and  when  not  sufficiently  present  in  the  food,  may  be  absorbed 
from  the  teeth. 

What  mental  disturbances  are  met  with  in  pregnancy? 

The  woman  may  become  irritable,  peevish,  and  capricious.  She 
may  have  absurd  cravings  for  strong  or  extraordinary  articles  of  food 
(pica),  or  may  even  develop  mania.  The  latter  however  is  apt  to  be  a 
manifestation  of  some  form  of  toxemia 

What  effect  does  pregnancy  have  on  chorea? 

It  is  more  common  in  primigravidae.  Pregnancy  increases  the 
number  and  severity  of  the  attacks.     Abortion  is  common. 

What  is  the  treatment? 

The  same  as  in  the  non-pregnant  state — tonics,  antirheumatics,  and 
'  outdoor  life.      Arsenic,  the  salicylates,  and  cimicifuga  have  been  espe- 
cially recommended  as  remedies. 

What  effect  has  pregnancy  on  the  infectious  diseases  generally? 

It  increases  the  gravity  of  the  prognosis  both  for  mother  and  child. 


PATHOLOGY   OF   PREGNANCY  87 

The  danger  to  both  increases  in  proportion  to  the  height  of  the  tem- 
perature. The  child  may  die  from  the  disease  or  be  expelled  prior  to 
viability.  Probably  the  most  dangerous  to  mother  and  child  is 
variola. 

What  are  some  abnormalities  of  the  placenta? 

I.  Position — a  low  attachment  gives  rise  to  placenta  prsevia. 
/  Abnormally  large. 
\  Abnormally  small. 

3.  Weight. 

4.  Shape — usually  round,  may  be  irregular  or  horseshoe  shaped. 

5.  Number. 

6.  Edema. 

7.  Degeneration  of   villi,  due   to  fibrous,  caseous,  fatty,  calcareous, 
and  myxomatous  degenerations. 

8.  Syphilis. 

9.  Hemorrhages. 

10.  Cysts. 

{a.  Carcinomata. 
h.  Sarcomata. 
c.  Malignant  growths  at  the  placental  site,   usually 
carcinomatous. 

From  what  are  these  tumors  developed? 

The  sarcomata  from  the  decidual  cells;  the  carcinomata  from  the 
syncytium. 

Do  we  have  metastasis? 

Yes. 

What  is  placenta  membranacea? 

Placenta  membranacea  is  one  in  which  the  villi  persist  over  the 
entire  surface  of  the  chorion  and  are  of  equal  development. 

What  are  battledore  placenta  and  velamentous  insertion  of  the 
cord? 

Battledore  placenta  is  a  form  in  which  the  cord  is  inserted  at  the 
margin  of  the  placenta. 

If  the  vessels  from  the  cord  branch  out  before  reaching  the  placenta, 
it  is  termed  a  velamentous  insertion  of  the  cord. 

What  is  placenta  succenturia? 

Placentae  succenturiae  are  masses  of  placental  tissue  produced  by 
the  growth  of  isolated  patches  of  chorionic  villi.     The  vessels  of  each 


88  COMPEND    OF    OBSTETRICS 

patch  course  along  the  decidua  to  unite  with  those  going  to  the  cord. 
Each  child  may  have  its  own  placenta  in  multiple  pregnancies. 

What  is  the  diagnosis  of  the  death  of  the  fetus? 

1.  Failure,  after  repeated  examinations,  to  recognize  the  fetal  heart 
sounds  and  fetal  movements. 

2.  The  uterus  ceases  to  grow  and  becomes  flabby. 

3.  The  breasts  decrease  in  size  and  become  soft. 

4.  Peptonuria  and  disturbances  of  the  renal  function. 

5.  Diminution  of  the  cervical  temperature. 

6.  The  patient's  health  deteriorates;  she  suffers  from  chilly  sensations 
rand  a  feeling  of  weight  in  the  hypogastrium.  This  only  occurs  if 
[the  membranes  rupture  and  infection  occurs. 

7.  If  the  head  of  the  fetus  can  be  felt  through  the  os  uteri,  the  bones 
will  be  found  to  be  loose  and  movable. 

What  is  the  duration  of  pregnancy? 

Between  insemination  and  labor  two  hundred  and  seventy-five 
days;  between  the  end  of  menstruation  and  labor  two  hundred  and 
seventy-eight  days.  It  is  impossible  to  know  the  exact  duration  of 
pregnancy  unless  we  can  ascertain  the  precise  moment  of  conception. 

HYDATID  PREGNANCY 

What  is  hydatid  pregnancy? 

Pregnancy  in  which  cystic  degeneration  of  the  chorionic  villi  oc- 
curs, caused  by  a  hyperplasia  of  the  mucous  tissue,  normally  form- 
ing the  fundamental  structure  of  the  villi  and  giving  rise  to  what  is 
called  a  hydatidiform  mole. 

1.  The  villi  are  converted  into  cysts  arranged  like  bunches  of  grapes, 
in  size  from  a  hemp  seed  to  a  bean. 

2.  The  embryo  dies  and  is  absorbed. 

3.  The  uterus  is  finally  filled  entirely  with  small  cysts,  whose  average 
size  and  appearance  are  those  of  a  white  currant.  It  occurs  about 
once  in  two  thousand  pregnancies. 

What  is  the  microscopical  appearance  of  these  cysts? 

Their  surfaces  show  the  usual  epithelium  of  the  villus,  but  beneath 
this  is  a  delicate  layer  of  cells,  spindle  or  stellate  in  character. 
These  enclose  the  gelatinous  semi-fluid  masses  which  are  produced  by 
a  myxomatous  degeneration  of  the  cells.  The  blood  supply  of  the 
vesicles  is .  generally  much  decreased.  A  secondary  increase  of  the 
fibrous  portion  of  the  villi  sometimes  occurs. 


PATHOLOGY    OF    PREGNANCY 


89 


What  are  its  symptoms  and  termination? 

T.  The  pregnancy  begins  normally,  but  in  the  second  or  third  month — 

2.  A  sudden  and  rapid  increase  in  size  of  the  uterus  occurs,  accom- 
panied— 

3.  By  pain  and  irregular  discharge  of  blood  and  water. 

4.  Labor  supervenes  and  the  mass  of' cysts  is  expelled. 

It  should  be  remembered  that  true  hydatids  (echinococci)  may 
occur  in  the  uterus,  but  not  as  a  result  or  accompaniment  of  pregnancy. 

What  is  the  prognosis? 

The  danger  to  the  child  is  in  direct  proportion  to  the  extent  of 
villous  involvement.  As  a  general  rule,  the  child  dies.  About 
13  per  cent,  of  women  who  are  affected  with  the  disease  die. 

What  secondary  dangers  have  resulted  from  this  condition? 

Destruction  of  uterine  tissue  by 
penetration  of  the  diseased  villi 
into  the  sinuses,  causing  adherence 
of  the  placenta.  Perforation  of 
the  uterus  may  occur.  Uterine 
rupture  has  followed  this  disease. 
Death  may  occur  from  hemor- 
rhage. Chorioepithelioma  may  ap- 
pear secondarily. 

What  is  the  treatment  of  hydat- 
idiform  mole? 

As  soon  as  discovered,  the 
uterine  contents  should  be  evac- 
uated at  once,  providing  the  fetus 
is  dead.  The  strictest  antisepsis 
should  be  employed.  The  patient 
should  be  carefully  watched  for 
several  months  afterward  for  cho- 
rioepithelioma. 

What  is  mole  pregnancy? 

1.  At  some  time  during  the  first 
three  months  of  pregnancy  a 
hemorrhage  takes  place  in  the 
ovum. 

2.  The  embryo  is  destroyed  and  disappears,   while  the  vitality  of 
the  chorion  is  maintained  for  several  weeks  or  months. 


Hydatidiform  Mole. 


go  COMPEND   OF   OBSTETRICS 

3.  Labor  supervenes,  and  a  fleshy,  laminated  mass  or  mole  is  ex- 
truded, in  which  close  search  will  always  reveal  chorionic  villi  and 
patches  of  the  fetal  membranes. 

What  is  hydrorrhoea  gravidarum? 

A  watery  discharge  from  the*  uterus,  from — 

1.  Hydatid  pregnancy. 

2.  A  tear  in  the  fetal  membranes  at  a  point  remote  from  the  os 
uteri,  with  gradual  leaking  of  liquor  amnii. 

3.  Probably  from  a  watery  secretion,  or  transudation  from  the 
uterine  mucous  membrane,  caused  by  increased  proliferation  of 
the  uterine  glands  of  the  decidua  vera. 

What  is  myxoma  fibrosum? 

This  is  a  rare  disease  affecting  the  placental  portion  of  the  chorion, 
and  occurs  in  the  latter  part  of  pregnancy.  It  consists  of  a  fibroid 
degeneration  of  the  connective  tissue  of  that  part  of  the  chorion 
which  is  situated  over  the  placental  site,  accompanied  by  the  forma- 
tion of  small  growths.  The  latter  subsequently  undergo  a  myxoma- 
tous degeneration.  The  condition  is  also  known  as  fibromyxomatous 
degeneration  of  the  chorion. 

What  is  chorioepithelioma  or  malignant  deciduoma? 

This  is  a  malignant  degeneration  of  retained  decidual  debris, 
characterized  by  a  tendency  to  the  formation  of  metastatic  deposits 
throughout  the  body,  and  proving  rapidly  fatal  in  from  five  to  six 
months  after  delivery.  It  may  follow  cystic  disease  of  the  chorion. 
(Borland.) 

What  is  the  treatment? 

Hysterectomy.  Curettage  and  packing  with  iodoform  gauze  are 
sometimes  resorted  to,  but  the  growth  promptly  returns. 

What  other  name  is  sometimes  given  to  these  growths? 
Syncytial  tumors. 

What  is  placental  apoplexy? 

(a)  An  effusion  may  take  place  directly  into  one  or  more  placental 
cotyledons,  forming  small  soft  clots. 

(&)  In  this  form  destruction  of  portions  of  the  placenta  takes 
place,  forming  irregular  cavities  which  are  surrounded  by  infil- 
trated and  reddened  areas. 


PATHOLOGY   OF   PREGNANCY  9 1 

(c)  The  effusion  occupies  a  number  of  irregular  cavities  of  varying 
sizes  wMch  are  not  surrounded  by  areas  of  infiltration. 

What  are  the  characteristics  of  a  syphilitic  placenta? 

A  syphilitic  placenta  is  characterized  by  its  thickness  and  density; 
its  surface  and  substance  are  studded  with  cherry-like  nodules. 
It  color  is  paler  tjian  normal. 

What  is  calcareous  degeneration  of  the  placenta? 

Calcareous  degeneration  of  the  placenta  consists  of  deposits  of 
lime  salts  in  the  placenta  in  the  form  of  fine  sand-like  particles  or 
as  scales,  and  usually  occur  at  the  edges. 

What  are  white  infarctions? 

White  infarctions  are  yellowish  or  grayish  masses  of  degenerated 
placental  tissue,  and  are  of  no  pathological  significance,  except 
they  be  extensive,  when  fetal  death  may  result. 

What  is  fatty  degeneration  of  the  placenta? 

Fatty  degeneration  of  the  placenta  is  due  to  local  obstruction 
of  the  blood  supply  to  the  part  affected.  If  the  area  is  extensive, 
the  fetus  is  liable  to  perish  from  disordered  function  of  the  placental 
blood  supply. 

What  are  some  of  the  abnormalities  of  the  amnion? 

..  ,.,.        .  ^.         /  Oligohydramnios. 

1.  Abnormalities  of  secretion.   <  tt    i  • 

[  Hydrammos. 

2.  Abnormalities  of  consistency,  color,  and  chemical  constitution. 

3.  Putrefaction  of  liquor  amnii,  usually  associated  with  death  and 
putrefaction  of  fetus.  An  intense  putrid  odor  of  the  liquor  amnii, 
with  physometra,  has  been  noticed,  yet  the  child  has  been  born 
alive. 

4.  Adhesive  inflammation  and  formation  of  amniotic  bands.  These 
bands  may  even  amputate  limbs  and  also  cut  off  the  blood  supply 
by  becoming  wrapped  around  the  cord. 

5.  Cysts. 

From  what  source  is  the  amniotic  fluid  obtained? 

From  both  mother  and  fetus. 

(a)  It  has  been  demonstrated  by  injecting  sodium  sulphindigo- 
late  into  veins  of  pregnant  rabbits  and  afterward  the  blue  colora- 
tion was  found  in  amniotic  fluid. 


92  eOMPEND    OF    OBSTETRICS 

(b)  The  excretion  of  urine  during  the  latter  part  of  fetal  life  reaches 
to  a  considerable  amount.  More  than  three  pints  have  been  found 
retained  in  fetal  urine. 

HYDRAMNIOS 

What  is  hydramnios? 

An  excess  in  the  amount  of  liquor  amnii. 

What  is  the  etiology  of  hydramnios? 

There  are  various  theories,  as  follows: 

1.  Patulous  condition  of  the  vasa  propria. 

2.  Disease  of  the  fetal  heart,  lungs,  or  liver. 

3.  Increased  activity  of  the  kidneys. 

4.  Changes  in  the  maternal  circulation. 

5.  A  morbid  condition  of  the  decidua,  chorion,  and  amnion. 

6.  Syphilis. 

The  disease  is  more  frequent  in  multigravida  than  in  primigravida. 

How  many  forms  of  the  disease  are  described? 

Two:  an  acute  and  chronic  form. 

What  are  the  symptoms  of  hydramnios? 

1.  Rapid  development  of  the  uterus. 

2.  The  uterine  waUs  are  tense  and  elastic. 

3.  Obscure  sense  of  fluctuation. 

4.  Fetal  heart  sounds  faint  or  absent. 

5.  Fetus  cannot  be  recognized  by  palpation. 

6.  The  cervix  is  high  up  and  more  or  less  shortened. 

7.  The  fetus  moves  from  one  position  to  another  with  great  ease. 
Other  symptoms  are:  dyspncea,  palpitation  of  the  heart,  irrita- 
bility of  the  stomach,  edema  of  the  lower  extremities,  and  inguinal, 
lumbar,  sacral,  and  abdominal  pains. 

The  symptoms  occur,  as  a  rule,  about  the  fifth  or  sixth  month; 
in  some  cases  earlier.     The  accumulation  of  fluid  is  gradual. 

In  the  acute  form  the  accumulation  of  fluid  may  take  place  in  a 
few  days;  in  addition  to  the  symptoms  of  the  chronic  form,  fever, 
vomiting,  and  intense  pain  are  present. 

What  is  the  diagnosis? 

The  diagnosis  depends  upon  the  subjective  and  objective  symp- 
toms already  described.  Braxton  Hicks'  sign  is  of  great  value  in 
determining  the  existence  of  pregnancy.  Hydramnios  may  be 
mistaken  for  a  multiple  pregnancy. 


SIGNS    OF   PREGNANCY  93 

What  is  the  prognosis? 

Very  -grave  for  the  child:  nearly  one-fourth  die.  The  prognosis 
for  the  mother  is  favorable,  unless  the  disease  is  associated  with 
an  organic  affection  of  the  heart.  The  danger  of  post-partum 
hemorrhage  should  not  be  forgotten. 

How  is  the  treatment  divided? 

Into  I,  the  expectant  plan;  2,  the  active  plan. 

The  former  consists  of  the  use  of  an  abdominal  supporter  and 
refraining  from  active  exercise.  The  latter,  or  active  plan  of  treat- 
ment, is  indicated  whenever  grave  symptoms  are  present,  due  to 
over-distention,  and  when  there  are  serious  disturbances  of  the 
mother's  heart.  The  indication  is  to  induce  abortion  or  premature 
labor.  The  membranes  should  be  punctured  high  up,  and  in  the 
interval  of  the  pains.  The  hand  should  be  used  as  a  plug  in  the  vagina 
to  prevent  the  rapid  discharge  of  the  liquor  anmii.  If  the  presenta- 
tion is  normal,  leave  the  further  progress  of  the  case  to  nature; 
version  is  indicated  if  the  fetus  presents  by  the  shoulders.  Prophy- 
lactic measures  should  be  taken  against  post-partum  hemorrhage. 

What  is  oligohydramnios? 

A  deficient  amount  of  amniotic  liquid.  The  quantity  may  be  so 
far  below  normal  as  to  seriously  interfere  with  the  growth  and  de- 
velopment of  the  fetus,  and  may  cause  premature  expulsion  or  de- 
formities.    The  cause  is  unknown. 


THE  SIGNS  OF  PREGNANCY 

What  are  the  signs  of  pregnancy? 

The  symptoms  and  physical  signs  caused  by  the  changes  taking 
place  in  the  woman,  and  by  which  we  recognize  the  occurrence. 

How  may  they  be  classified? 

1.  Into  certain  and  presumptive,  or 

2.  Into  objective  and  subjective,  or 

3.  According  to  their  etiology,  viz. : 

I.  Signs  due  to  the  increase  of  vital  activity. 
II.  Signs  due  to  the  development  of  the  womb, 
III.  Signs  due  to  the  presence  of  a  fetus. 

IV.  Signs  due  to  the  unequal  development  of  the  general  and  genera- 
tive systems,  or  semi-pathological  signs. 


94  COMPEND    OF    OBSTETRICS 

What  do  we  understand  by  the  objective,  or  certain  signs  of 
pregnancy? 

They  are  those  which  the  obstetrician  can  see,  feel,  and  hear 
for  himself,  by  the  use  of  various  scientific  methods. 

What  is  Abderhalden's  test  for  pregnancy? 

This  is  a  biologic  test  for  pregnancy  and  depends  on  the  presence  of 
certain  ferments  found  in  the  blood  serum  of  pregnant  animals  or  in 
the  pregnant  human  female.  This  test  is  considered  fairly  reliable 
but  is  very  complex  and  for  the  detailed  description  the  student  is 
referred  to  "Webster's  Diagnostic  Methods"  or  other  text-books. 

What  are  the  subjective  signs  of  pregnancy? 

Those  which  are  given  us  by  the  words  of  the  patient  herself. 

What  are  the  signs  due  to  an  increase  of  vital  activity? 

The  pregnant  condition  requires  that  the  woman  shall  supply,  not 
only  the  needs  of  her  own  organism,  as  before,  but  shall  also  build  up 
from  10  to  20  pounds  of  highly  organized  tissue,  viz.:  the  child 
and  its  envelops.  Therefore,  she  will  need  more  blood,  and,  in  general, 
all  the  vital  forces  must  be  increased.  This  is  brought  about  by  the 
stimulus  of  fecundation,  and  results  in  (a)  increase  of  appetite,  (&) 
weight,  (c)  vigor,  and,  perhaps,  {d)  sexual  appetite.  She  must  eat 
more  in  order  to  make  more  blood;  the  increased  blood  supply  will 
increase  her  weight  and  general  vigor,  while  locally  the  hyperemia  of 
the  pelvic  organs  may  cause,  at  first,  an  increase  in  the  sexual  desire^ 

Is  this  class  of  signs  always  present  in  pregnancy? 

No.  The  general  system  may  fail  to  respond  to  the  stimulus  of 
fecundation,  and  these  signs  will  be  absent  or  defective,  being  replaced 
by  the  fourth  class. 

What  signs  are  due  directly  to  the  development  of  the  womb? 

1.  The  descent  of  the  womb,  due  to  its  increased  weight,  causes  the 
abdomen  to  become  smaller  and  flatter  during  the  first  month  or 
two.     The  umbilicus  also  becomes  deeper,  for  the  same  reason. 

2.  Afterward  the  womb  enlarges  at  a  particular  rate,  differing  from 
that  of  other  tumors. 

3.  Certain  changes  occur  in  the  body  of  the  uterus,  the  cervix, 
vagina,  and  external  organs. 

What  changes  are  found  in  the  cervix? 

It  becomes  sojter  and  deeper  red  in  color;  in  many  cases,  the 
mucous  membrane  has  a  bluish  tint.     The  ascent  of  the  uterus  and 


SIGNS    OF    PREGNANCY  95 

retraction  of  the  vagina  give  the  sensation  of  shortening,  though  in 
reality  it  becomes  longer.  Some  increase  in  the  mucous  secretion  of 
its  cavity  is  also  noticed. 

What  changes  are  found  in  the  body  of  the  uterus? 

It  becomes  more  globular  or  jug-shaped,  and  can  be  easily  recognized 
in  all  the  vaginah  cul-de-sacs,  but  particularly  the  lateral  and  posterior 
ones.  The  body  also  becomes  softer.  Palpation  of  the  lower  uterine 
segment  by  means  of  the  finger  in  the  posterior  cul-de-sa'c  will  demon- 
strate considerable  softening.  The  above  are  diagnostic  points  which 
can  be  recognized  early  (about  the  second  month)  in  pregnancy  and 
are  of  considerable  value.  This  softening  of  the  lower  uterine  seg- 
ment is  also  known  as  Regards  sign  of  pregnancy? 

What  changes  occur  in  the  vagina  and  external  organs? 

The  increased  blood  supply  causes  the  vagina  to  become  deep  red  or 
violet  in  color;  the  external  organs  are  somewhat  enlarged,  and  the 
perineum  is  doubled  in  its  antero-posterior  measurement,  during 
pregnancy. 

With  what  other  tumors  may  the  pregnant  womb  be  confounded? 

The  enlargement  of  the  abdomen  may  be  due  to  fibroid,  ovarian, 
and  other  pelvic  tumors ;  to  ascites,  flatulence,  or  even  excessive  deposits 
oj  fat  in  the  abdominal  walls  or  mesentery. 

Give  differential  diagnosis  between  fibroid  tumors  and  pregnancy. 

In  fibroids,  palpation  shows  the  uterus  to  be  hard,  resisting,  and 
irregular  in  shape.  Menstruation  is  present,  often  profuse.  The 
fetus  cannot  be  outlined,  nor  its  heart-sounds  heard.  Fibroid  tumors 
are  of  slow  growth.  In  pregnancy,  the  uterus  is  more  regular  in  shape 
and  growth;  menstruation  is  generally  absent;  the  increase  in  the  size 
of  the  uterus  is  rapid;  fetal  heart-sounds  can  be  heard,  and  the  fetus 
outlined  by  palpation. 

Between  ovarian  cyst  and  pregnancy. 

An  ovarian  cyst  is  apt  to  be  unilateral  in  location,  its  growth  is  slow, 
and  the  general  health  is  bad,  as  is  shown  in  the  face  and  form  of  the 
patient.  Fluctuation  and  signs  of  fluid  are  present;  menstruation  is 
present.  The  objective  symptoms  of  pregnancy  are  absent.  In 
pregnancy,  the  tumor  is  median  in  position;  grows  more  rapidly;  the 
health  is  generally  good;  very  little  or  no  fluctuation,  except  in 
hydramnios,  when  the  fluctuation  is  principally  in  the  upper  part  of 
the  abdomen;  subjective  and  objective  symptoms  present. 
7 


96  COMPEND    OF    OBSTETRICS 

Between  ascites  and  pregnancy. 

In  ascites  there  is  general  fluctuation,  percussion  dulness  increas- 
ing from  above  downward.  When  patient  is  lying  on  her  back, 
it  is  clear  in  the  median  line,  becoming  dull  as  we  proceed  toward 
the  flanks.  Subjective  and  objective  signs  of  pregnancy  are  ab- 
sent. In  pregnancy,  fluctuation  is  absent,  except  in  hydramnios; 
percussion  shows  dulness  in  the  median  line,  clear  at  the  flanks;  dul- 
ness remains  constant. 

Between  excessive  deposits  of  fat  in  the  abdominal  wall  and 
pregnancy. 

The  first  occur  late  in  life;  the  patient  shows  similar  deposits 
of  fat  in  other  parts  of  the  body;  objective  and  subjective  signs 
absent. 

What  is  spurious  pregnancy? 

Called  also  pseudocyesis,  is  a  condition  in  which  some  of  the  symp- 
toms of  pregnancy  are  present,  especially  enlargement  of  the  abdo- 
men, changes  in  the  breasts,  and  subjective  feeling  of  the  fetal  move- 
ments, the  woman  not  being  pregnant.  It  is  to  be  distinguished 
from  feigned  pregnancy. 

How  may  it  be  disposed  of? 

A  vaginal  examination  shows  the  womb  to  be  not  enlarged,  and 
the  administration  of  ether  will  cause  the  abdominal  enlargement 
to  suddenly  disappear,  when  not  due  to  increase  of  fat  in  the  ab- 
dominal walls.  No  fetal  heart-sounds  can  be  heard,  the  fetal  move- 
ments cannot  be  felt,  nor  can  the  child  be  outlined  by '  palpation. 
It  sometimes  terminates  in  spurious  labor,  a  condition  in  which  the 
clinical  phenomena  of  labor  are  present  in  some  degree. 

What  changes  are  due  indirectly  to  the  development  of  the  womb? 

Lines  from  distention,  a  median  brown  line,  the  cessation  of  men- 
struation, contractions  of  the  uterine  walls,  and  certain  changes  in 
the  breasts. 

Are  these  signs  found  only  in  pregnancy? 

Each  one  of  them  is  found  to  accompany  other  conditions,  but 
when  aU  or  many  of  them  are  present,  they  furnish  strong  presumptive 
proof. 


SIGNS    OF   PREGNANCY  97 

What  are  lines  from  distention? 

Called  also  linecz  albicantes;  they  are  small  patches  of  shining 
tissue,  whiter  than  the  surrounding  skin,  found  on  the  lower  part 
of  the  abdomen,  especially  in  the  iliac  regions,  upon  the  flanks, 
thighs,  and  sometimes  upon  the  breasts.  They  look  like  small 
"gores"  inserted  in  the  skin,  or  like  cicatricial  tissue.  Their  average 
size  I  inch  long  and  1/4  inch  broad. 

Are  they  due  to  distention  or  stretching  of  the  skin? 

Being  found  on  the  thighs,  and  also  in  young  girls  with  rapid 
development  of  the  hips,  they  are  probably  due  only  to  rapid  growth 
of  the  skin.  They  rarely  disappear,  and  are,  therefore,  only  of  value 
in  a  first  pregnancy. 

What  is  the  median  brown  line? 

A  narrow,  brownish,  discoloration  of  the  abdominal  skin,  extend- 
ing from  the  symphysis  to  the  ensiform  appendix,  in  the  median 
line,  and  of  little  value  as  a  sign  of  pregnancy. 

Is  menstruation  always  suspended  by  pregnancy? 

In  the  great  majority  of  cases.  Some  women  continue  to  men- 
struate for  a  month  or  for  several  months;  a  very  few  menstruate 
throughout  pregnancy;  a  few  cases  are  recorded  in  which  the  women 
menstruated  only  when  pregnant.  As  the  decidua  reflexa  is  not 
usually  united  to  the  vera  for  the  first  three  months,  there  may  be  a 
menstrual  hemorrhage  from  the  womb  during  that  time;  but  it  is 
probable  that  any  bloody  discharge  from  the  genital  tract  after 
the  first  month  of  pregnancy  is  not  a  true  menstruation,  but  a  hemor- 
rhage, and  an  indication  of  threatening  abortion.  The  real  reason 
for  the  cessation  of  menstruation  is  the  effect  which  fecundation 
produces  upon  the  system. 

Is  menstruation  stopped  by  other  things  than  pregnancy? 

If  often  ceases  after  a  few  months  in  newly  married  women,  and 
may  be  stopped  for  one  or  more  periods  by  mental  emotion,  change 
of  climate,  especially  if  following  a  sea  voyage,  acute  or  chronic  disease, 
and  especially  phthisis. 

What  is  meant  by  contraction  of  the  uterus  during  pregnancy? 

The  walls  of^the  uterus  are  always  in  a  state  of  intermittent  con- 
traction. Hence  the  hand  of  the  physician  placed  on  the  abdomen 
of  a  woman  may  detect  them  (the  womb  becoming  harder)  every 
twenty  or  thirty  minutes  (Braxton  Hick's  sign). 


98  COMPEND    OF    OBSTETRICS 

What  changes  occur  in  the  breasts? 

1.  They  may  become  enlarged. 

2.  Pain  or  discomfort  may  be  felt. 

3.  They  may  contain  milk,  which  can  be  pressed  from  the  nipple. 

4.  The  nipple  and  areola  become  darker  (sometimes  almost  black). 

5.  A  circular  ring  of  dark  splotches  may  be  developed  at  a  short 
distance  from  the  areola,  called  the  secondary  areola,  developed 
after  the  fifth  month. 

6.  The  sebaceous  follicles  about  the  areola  become  enlarged  and 
contain  sebaceous  matter, 

7.  Linese  albicantes  may  appear  on  them. 

One  or  more  of  these  changes  are  always  present  in  pregnancy, 
though  any  of  them  may  occur  in  other  conditions.  Their  presence, 
therefore,  is  of  less  importance  than  their  absence,  in  settling  a  diag- 
nosis. 

Which  of  the  signs  of  pregnancy  are  certain  signs? 

Those  due  to  the  presence  of  the  fetus,  and  of  these  but  two  are 
absolutely  certain,  viz.:  the  sound  of  the  fetal  heart,  and  outHning 
the  fetus  by  palpation.  Except  in  the  very  rare  instances  before 
mentioned,  the  peculiar  feeling  caused  by  the  impact  of  the  fetal 
parts  against  the  abdominal  wall  can  be  counted  among  the  posi- 
tive signs  of  pregnancy. 

Which  of  the  presumptive  signs  are  the  most  important? 

The  cessation  of  menstruation;  the  regular  and  symmetrical 
development  of  the  uterus;  the  changes  in  the  breast;  morning  sick- 
ness, and  quickening. 

At  what  date  are  the  important  signs  available? 

1.  The  fetal  heart,  rarely  before  the  fourth  month.  They  cannot  be 
heard  with  any  certainty  before  the  sixth  month. 

2.  Ballottement,  third  to  fifth  month,  but  its  failure  may  be  due 
to  want  of  skill  and  other  causes. 

3.  The  cessation  of  menstruation,  usuahy  after  the  time  for  the 
first  period,  or  immediate.  Amenorrhea  is  always  a  suspicious 
circumstance  in  healthy  women,  previously  regular,  whether  married 
or  not,  when  not  accompanied  by  ill  health  in  some  form. 

4.  The  increased  size  of  the  uterus  may  almost  always  be  made 
out  by  bimanual  touch,  at  from  four  to  six  weeks.  If  at  a  second 
examination,  a  month  later,  a  further  symmetrical  enlargement, 


SIGNS    OF    PREGNANCY  99 

at  the  usual  rate,  is  noted,  the  fact  of  pregnancy  is  scarcely  to  be 
doubted. 

What  are  the  signs  due  to  the  presence  of  a  fetus? 

1.  The  sounds  of  the  fetal  heart. 

2.  Fetal  movements. 

3.  Fetal  parts  found  on  palpation. 

4.  The  utero-placental  souffle. 

5.  The  funic  souffle,  and 

6.  Ballottement. 

What  is  meant  by  the  fetal  heart-sounds  ? 

At  any  time  during  the  latter  half  of  pregnancy,  the  beating  of 
the  fetal  heart  may  be  heard  by  placing  the  ear  (or  stethoscope) 
over  the  abdomen  of  the  mother,  the  heart  sounds  being  distinguished 
from  the  maternal  cardiac  pulsations  by  differences  of  rhythm. 

What  does  the  sound  resemble? 

The  ticking  of  a  watch  under  the  pillow,  with  a  rate  of  1 15-160 
pulsations  per  minute. 

Where  and  when  are  heart-sounds  best  heard? 

When  at  the  earliest  period  (about  the  fourth  month)  at  which 
the  heart- sounds  are  audible  they  are  best  heard  over  the  fundus 
uteri;  after  that  time  the  point  of  maximum  intensity  varies  with 
the  position  and  presentation. 

Where  are  they  best  heard  in  the  various  presentations? 

The  abdomen  being  divided  into  four  parts  or  quadrants  by  two 
imaginary  lines,  one  extending  from  the  ensiform  cartilage  to  the 
pubes,  the  other,  the  transverse,  dividing  the  uterus  into  two  equal 
parts;  in  vertex  presentations  the  heart-sounds  are  best  heard 
below  the  transverse  and  to  the  right  or  left  of  the  perpendicular 
line. 

In  Face  presentations,  on  the  transverse,  and  to  the  left  or  right 
of  the  perpendicular  line. 

In  Breech  presentations,  usually  to  the  left  or  right  of  the  central 
line  and  somewhat  higher  than  the  corresponding  vertex  presentation 
would  be. 

In  Shoulder  presentations  the  heart-sounds  are  usually  heard 
at  or  near  the  perpendicular  line. 


lOO  COMPEND    OF    OBSTETRICS 

What  are  the  fetal  movements? 

The  fetus  moves  about  freely,  and  strikes  out  with  feet  and  hands 
against  the  uterine  wall.  If  the  hand  of  the  observer  is  placed 
against  the  mother's  abdomen,  these  slight  blows  may  be  felt.  If 
not  felt  at  once,  they  may  sometimes  be  produced  by  wetting  the 
hand  in  cold  water  and  applying  it  suddenly  to  the  abdomen.  This 
causes  contraction  of  the  uterus,  which  inconveniences  the  fetus 
and  causes  it  to  make  demonstrations. 

When  can  the  fetal  movements  be  first  felt? 

Not  until  after  the  fourth  month,  or  until  the  uterine  and  abdominal 
walls  have  come  in  contact. 

Can  the  fetal  movements  be  simulated  by  anything  else? 

Some  women  have  the  power  to  contract  their  abdominal  muscles 
suddenly  and  irregularly,  so  as  to  simulate  the  fetal  movements. 
Such  instances  are  rare.  Women  often  imagine  they  feel  the  fetal 
movements,  when  in  reality  they  are  not  pregnant  at  all. 

What  is  palpation? 

This  consists  in  gentle  manual  pressure  made  with  both  hands  for 
the  purpose  of  ascertaining  the  position  of  the  fetus  in  utero. 

How  is  palpation  performed? 

The  woman,  after  having  her  bladder  emptied  and  the  rectum 
thoroughly  evacuated  either  by  an  enema  or  purgative,  lies  on  a 
bed  with  limbs  extended,  the  abdomen  being  covered  only  by  a 
sheet.  The  physician,  standing  at  the  side  of  the  bed,  places  his 
hands  with  the  palms  together,  the  ulnar  side  down,  the  finger 
tips  being  immediately  above  the  mons  veneris.  The  hands  are 
now  gradually  separated  and  passed  upward  along  the  abdomen, 
gently  pressing  and  outlining  the  fetus  between  them. 

How  are  the  different  fetal  parts  recognized  by  palpation? 

The  head  can  be  recognized  as  a  hard  globe,  more  or  less  movable; 
the  breech  as  a  larger,  less  movable,  body,  at  some  distance  from  the 
head;  in  its  neighborhood  small  movable  bodies,  the  feet,  can  be 
felt.  Between  the  head  and  breech  a  ridge,  hard  and  little  movable, 
can  be  made  out;  this  is  the  back  of  the  fetus. 

What  is  the  utero -placental  souffle? 

A  bruit  or  whirring  sound  synchronous  with  the  mother's  pulse, 
which  may  sometimes  be  heard  in  the  abdomen.     It  is  variously 


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SIGNS    OF   PREGNANCY  lOI 

'  supposed  to  be  produced  in  the  uterine  sinuses,  the  placental  circula- 
tion, the  uterine  or  hypogastric  arteries,  and  elsewhere.  It  is  heard 
also  in  some  fibroid  tumors.  It  is  of  little  use  as  a  positive  sign  of 
pregnancy. 

What  is  the  funic  souflae? 

A  similar  but  less  intense  bruit,  synchronous  with  the  fetal  heart, 
and  supposed  to  be  produced  in  the  vessels  of  the  funis.  It  is  rarely 
heard. 

What  is  ballottement? 

If,  when  the  woman  is  in  the  erect  posture,  a  finger  (introduced  into 
the  vagina)  is  pushed  suddenly  against  the  anterior  wall  of  the  womb, 
the  fetus,  if  present,  will  first  be  pushed  up  into  the  liquor  amnii,  and 
will  then  drop  back.  If  the  finger  is  held  in  position,  the  return  of  the 
fetus  to  its  resting  place  may  be  felt  and  recognized.  The  manoeuver 
is  called  ballottement,  and  may  be  practised  between  the  third  and 
fifth  months,  inclusive. 

What  is  quickening  or  "feeling  life"? 

The  time  9.t  which  the  mother  first  feels  the  fetal  movements.  The 
escape  of  the  uterus  from  the  pelvis  (which  is  a  requisite  for  feeling 
the  movements)  is  sometimes  sudden,  and  attended  by  peculiar 
sensations  and  faintness.  It  occurs  about  the  i6th  to  the  1 8th 
week  of  pregnancy. 

What  is  the  duration  of  pregnancy? 

It  is  somewhat  variable,  but  is  sufficiently  accurate  to  regard  as 
continuing  through  ten  menstrual  periods,  ten  lunar  months,  or  280 
days. 

What  are  the  limits  of  variation? 

From  245  to  300  days,  with  possibilities  in  either  direction. 

What  method  is  usually  employed  to  calculate  the  duration? 

Count  nine  calendar  months  forward  (or  three  backward)  from  the 
date  of  the  last  menstruation;  add  to  this  seven  days.  Ex.:  End  of 
menstruation,  January  loth;  three  rnonths  back  =  October  loth; 
add  seven  days  =  October  17th,  as  the  probable  date  of  confinement. 

What  causes  pregnancy  to  come  to  an  end? 

The  important  theories  are — ■ 
I.  Power's.     The  uterus  is  a  peristaltic  tube,  with  circular  fibers  in 


102  COMPEND    OF    OBSTETRICS 

the  cervix  acting  as  a  sphincter.  As  the  child  grows  it  presses  upon 
this  sphincter,  and  the  sum  of  all  successive  irritations  finally  causes 
it  to  relax,  and  the  uterus  to  expel  the  child. 

2.  King's.  The  uterus  has  a  definite  limit  of  growth.  The  fetus 
does  not  attain  its  limit  of  growth  in  utero,  and  therefore  distends  the 
uterus  when  the  latter  stops  growing.  This  irritates  the  uterine 
fiber  and  causes  it  to  contract  and  expel  its  contents. 

3.  The  foreign  body  theory.  The  womb  is  always  irritated  into 
contracting  upon  a  foreign  body,  and  the  fetus  becomes  such  a 
body  at  the  end  of  pregnancy.  There  is  probably  truth  in  each  view 
of  the  matter. 

Why  is  the  ovum  not  a  foreign  body  during  pregnancy? 

Because  of  the  intimate  vascular  connections  between  the  chorion 
and  the  uterine  mucous  membrane. 

How  does  the  ovum  become  a  foreign  body? 

By  the  fatty  degeneration  and  atrophy  of  the  connections  between 
the  ovum  and  uterus,  which  occur  during  the  last  weeks  of  pregnancy. 

What  effect  has  this  upon  the  uterus? 

It  causes  a  gradually  increasing  irritation  of  the  muscular  fibers, 
contractions  are  excited  sufficiently  powerful  to  expel  the  child. 

LABOR 

What  is  labor? 

The  process  by  which  the  child  and  its  ovular  attachments  are 
expelled  from  the  womb. 

What  changes  take  place   in  the  female   organism  immediately 
before  labor  begins? 

1.  Owing  to  the  descent  of  the  presenting  part,  the  uterus  sinks  lower 
in  the  pelvis.  The  abdomen  then  becomes  somewhat  smaller, 
respiration  less  difficult,  and  by  a  decrease  of  pressure  on  the 
stomach,  digestion  may  be  improved.  The  bladder  is  now  pressed 
upon,  producing  irritability,  walking  is  more  difficult,  and  there  is 
apt  to  be  edema  of  the  lower  limbs.  This  sinking  of  the  uterus  is 
more  common  in  primiparas. 

2.  Hypersecretion  of  the  cervical  glands.  A  secretion  of  thick  glairy 
mucus  is  produced  by  the  cervdcal  glands.  Later,  owing  to  the 
partial  detachment  of  the  decidua  and  consequent  slight  hemor- 


LABOR  103 

rhage,  this  secretion  becomes  tinged  with  blood,  and  in  common 
language  is  spoken  of  as  "a  show." 
3.  The  labia  at  this  time  are  apt  to  he  somewhat  separated,  the  secretions 
of  the  vaginal  glands  are  increased,  and  relaxation  takes  place  in  its 
walls. 

What  essential  steps  occur  in  labor? 

1.  The  body  or  expulsive  portion  of  the  uterus  contracts. 

2.  The  enlargement  of  the  os  uteri  until  it  is  of  a  size  sufficient  to 
permit  the  passage  of  the  child.  There  is  also  dilatation  of  the  cer- 
vix and  vagina,  thus  making  the  birth  canal  a  tube  or  canal  bounded 
above  by  the  fundus  uteri  and  below  by  the  vulva.  This  is  some- 
times spoken  of  as  the  canalization  of  the  birth  canal. 

3.  The  expulsion  of  the  child. 

4.  The  expulsion  of  the  placenta  and  membranes,  also  called  the  after- 
birth, or  secundines. 

Into  how  many  steps  is  labor  divided? 

Into  three.     I.  The  stage  of    dilatation    and    canalization   of  the 
birth  canal. 
II.  The  stage  of  expulsion  of  the  child. 
III.  The  stage  of  expulsion  of  the  after-birth  or  placenta^ 

By  what  force  are  these  occurrences  produced? 

By  the  contraction  of  the  uterus,  aided  by  the  abdominal  muscles. 

What  are  the  contractions  of  the  uterus  called? 

Labor-pains,  because  usually  accompanied  by  painful  sensations  in 
the  back  or  hypogastrium. 

What  are  painless  uterine  contractions? 

These  are  contractions  of  the  uterine  muscle  felt  by  placing  the 
hand  upon  the  abdomen,  and  are  found  in  the  last  period  of  pregnancy. 
They  are  not  of  sufficient  force  to  excite  the  pain  sense. 

What  symptoms  are  of  the  greatest  importance  in  showing  that 
labor  has  actually  begun? 

Regular  uterine  contractions,  accompanied  by  the  dilatation  and 
effacement  of  the  cervix. 

How  long  does  a  contraction  last? 

Each  contraction  lasts^for  from  a  few  seconds  to  two  minutes. 
Their  duration  increases  with  the  progress  of  the  labor,  becoming 


I04  COMPEND    OF    OBSTETRICS 

longer  and  stronger  as  it  advances.  The  average  duration  is  a 
little  more  than  one  minute  (according  to  Westermarck,  about  69 
seconds). 

How  long  is  the  interval  between  them? 

At  the  beginning  of  labor  they  are  from  a  half  hour  to  ten  minutes 
apart.  The  interval  diminishes  as  labor  advances,  and  toward  the 
end  may  be  from  five  minutes  to  only  one  minute  apart. 

What  effect  have  the  contractions  upon  other  muscles? 

When  powerful,  or  when  the  second  stage  is  half  finished,  they 
are  accompanied  by  contractions  of  the  abdominal  muscles  which 
are  almost  entirely  involuntary,  and  the  woman  strains  or  "bears 
down."  The  muscles  of  the  extremities  also  become  rigid  during 
the  expulsive  effort. 

How  much  pain  accompanies  a  uterine  contraction? 

In  an  entirely  normal  labor  in  a  healthy  woman  the  pain  is  slight; 
in  any  case,  during  a  bearing-down  effort,  the  consequent  cerebral 
fulness  causes  some  physiological  anesthesia.  In  perhaps  the 
majority  of  labors  there  is  some  abnormal  condition  present  which 
makes  the  contractions  inconveniently  painful. 

What  are  the  characters  of  the  pains  at  each  stage? 

During  the  first  stage  of  labor  the  patient  usually  speaks  of  the 
pains  as  being  in  the  back,  in  the  lumbo-sacral  region,  and  of  a  grind- 
ing character.     They  frequently  extend  down  to  the  pubes. 

In  the  second  stage  the  pains  are  more  intense,  and  are  spoken 
of  as  "bearing-down  pains;"  they  are  referred  to  the  lower  part 
of  the  abdomen  and  vagina.  Cramps  occur  in  the  legs.  The 
woman  often  complains  of  sensations  of  tearing  and  stretching  of  the 
vaginal  and  perineal  tissues.  At  the  end  of  this  stage  the  uterine 
contractions  become  entirely  involuntary. 

How  is  the  dilatation  of  the  os  effected? 

1.  The  simultaneous  contraction  of  all  the  uterine  muscular  fibers 
tends  to  pull  apart  the  edges  of  the  os,  since  there  alone  the  fibers 
are  absent. 

2.  The  uterus  is  longer  than  broad,  and  its  longitudinal  fibers  more 
numerous  than  the  others;  therefore,  during  a  contraction  it  tends 
to  become  broader  than  long,  which  forces  the  contents  of  the 
uterus  against  the  os. 


LABOR  105 

3.  The  circular  fibers  about  the  os  undergo  a  spontaneous  dilatation, 
and  this  appears  to  be  increased  by  the  free  secretion  of  mucus 
from  the  cervical  glands. 

What  effect  upon  the  contents  of  the  uterus  may  be  noticed  during 
a  contraction? 

The  force  tends ^to  move  all  the  contents  (child  and  liquor  amnii) 
toward  the  os  uteri;  but  fluids  being  more  movable  than  solids,  the 
liquor  amnii  is  forced  toward  the  os,  while  the  ch^'ld  is  driven  away 
or  recedes  from  it. 

What  is  the  bag  of  waters,  and  how  formed? 

The  gradual  distention  of  the  membranes  b}?-  the  liquor  amnii, 
which  is  forced  in  advance  of  the  child,  forms  a  bag  filled  with  fluid 
in  the  os  uteri.  This  becomes  tense  during  a  pain  and  relaxed 
during  the  intervals,  and  by  its  even  pressure  greatly  aids  in  the 
dilating  process. 

Is  the  bag  of  waters  always  formed  in  labor,  and  what  variations 
occur? 

1.  Sometimes  the  amount  of  liquor  amnii  is  so  small  that  no  bag 
forms. 

2.  The  membranes  may  rupture  prematurely,  and  thus  prevent  it. 

3.  The  membranes  may  be  so  greatly  distended  that  the  bag  of 
waters  reaches  to  the  vulva.  Usually  it  contains  only  a  few  ounces 
of  fluid. 

Of  what  service  is  the  bag  of  waters  after  the  os  is  fully  dilated? 

Of  none;  and  the  progress  of  the  labor  is  suspended  until  the  con- 
tractions are  powerful  enough  to  rupture  the  membranes  and  permit 
the  escape  of  the  liquor  amnii. 

What  practical  deduction  follows  from  this? 

That  the  physician  should  rupture  the  membranes  as  soon  as  the 
OS  is  fully  dilated. 

How  is  expulsion  of  the  child  effected? 

By  the  contractions  of  the  uterus  aided  by  the  contraction  of  the 
abdominal  muscles,  and  according  to  a  definite  mechanism,  depending 
upon  the  manner  in  which  the  child  is  placed. 

How  is  the  after -birth  expelled? 

Theoretically,  the  placenta  becomes  folded  longitudinally,  ground 


Io6  COMPEND   OF   OBSTETRICS 

off  the  uterine  walls  by  contractions,  and  then  expelled.  If  nature 
does  not  do  this  in  a  short  time,  it  is  best  to  deliver  the  placenta  by 
manual  means.  The  expulsion  usually  takes  place  in  from  ten  to 
fifteen  minutes  after  the  birth  of  the  child. 

What  is  the  best  method  of  deUvering  the  placenta? 

The  method  of  Crede,  so  called  after  its  chief  promulgator. 

1.  Place  the  hand  upon  the  lower  part  of  the  abdomen  and  rub, 
stroke,  or  knead  the  uterus.  This  will  cause  the  womb  to  con- 
tract energetically,  and  in  so  doing  to  descend  and  move  forward. 
Then— 

2.  Grasp  the  uterus  through  the  abdominal  walls,  with  one  or  both 
hands,  and  squeeze  the  placenta  from  it.  If  successful,  the  escape 
of  the  placenta  may  be  recognized,  and  the  latter  will  be  found 
at  the  vulva,  or  even  shot  out  into  the  bed.  If  not,  wait  a  few 
minutes  and  repeat  both  manoeuvers.  If  the  placenta  is  dislodged 
as  far  as  the  vulva,  remove  it,  taking  care  to  twist  the  membranes 
into  a  rope,  by  rotating  the  placenta,  in  order  to  avoid  leaving 
any  strips  behind.     Never  pull  upon  the  umbilical  cord. 

What  other  advantages  has  this  method? 

It  secures  complete  contraction  of  the  uterus,  and  empties  the 
uterine  sinuses,  preventing  hemorrhage,  inversion  of  the  womb,  uter- 
ine thrombosis,  and  almost  all  other  complications. 

What  is  the  normal  duration  of  labor? 

It  is  variable.  Collins,  in  over  16,000  cases,  found  that  84  per 
cent,  completed  labor  within  six  hours  or  less.  It  is  probable  that 
in  strictly  normal  cases  of  multiparee  three  or  four  hours  should  suffice 
for  the  stage  of  dilatation  or  first  stage,  one  hour  for  the  second 
stage,  and  ten  to  thirty  minutes  in  subsequent  labors.  The  third 
stage,  being  artificial,  is  terminated  at  the  will  of  the  physician,  and 
should  rarely  be  delayed  longer  than  ten  or  fifteen  minutes.  The 
average  duration  in  primiparse  is  from  ten  to  fifteen  hours. 

Define  the  terms  primipara,  multipara,  etc. 

A  woman  in  her  first  pregnancy  and  labor  is  called  a  primipara; 
in  subsequent  labors  a  multipara,  or,  if  greater  accuracy  is  required, 
the  number  may  be  given  thus:  2  para,  3  para,  etc.;  one  who  has 
had  one  child,  and  is  not  now  pregnant,  is  called  a  unipara;  a  woman 
who  is  not  a  virgin,  but  who  has  never  had  a  child,  is  called  a  nulli- 


LABOR 


107 


para.     Adjectives  are  formed  from   these  words,  as,  a  primiparous 
woman,  etc. 

Why  is  labor  longer  in  primiparae  than  in  multiparse? 

Very  commonly  labor  comes  on  from  one  to  three  weeks  earlier 
in  primiparae;  consequently  the  changes  in  the  cervical  canal  are 
not  as  far    advanced,  and  dilatation  is  slower  than  in  multiparse. 


Fig.  41.  Fig.  42. 

Manner  in  which  Placenta  is  Expelled. 

During  the  second  stage  the  vagina  and  external  parts  of  the  primipara 
dilate  more  slowly,  and  thus  occupy  a  longer  time. 

What  foundation  is  there  for  the  statement  that  a  woman  who 
conceives  late  in  life  will  have  a  difficult  labor? 

An  old  primipara  is  apt  to  have,  first,  some  inflammatory  trouble 
of  the  cervix,  leading  to  difficulty  and  delay  in  the  first  stage,  and, 
second,  to  have  an  unyielding  sacro-coccygeal  or  pubic  joint,  delay- 
ing the  second  stage.  Otherwise  there  is  nothing  to  cause  a  difficult 
labor  in  these  cases. 


Io8  COMPEND    OF    OBSTETRICS 

What  are  the  ordinary  duties  of  the  physician  in  the  first  stage 
of  normal  labor? 

During  the  first  stage,  the  physician  should  see  that  his  patient 
has  a  room  as  comfortable  as  possible,  one  that  is  light,  well  venti- 
lated, does  not  open  directly  into  a  water-closet,  or  where  sewer 
gas  can  gain  access.  If  possible  there  should  be  an  open  fireplace 
in  the  lying-in  room.  Labor  having  begun,  he  should  see  that  the 
patient  is  given  a  bath,  her  hair  neatly  braided,  that  she  is  clad 
lightly  and  in  a  manner  giving  sufficient  warmth.  A  short  night 
dress  is  best,  as  it  does  not  become  soiled  during  the  delivery.  The 
patient's  bowels  should  be  well  opened  by  an  enema  of  glycerin 
and  water  or  soap  and  water,  and  care  should  be  taken  to  see  that 
no  urine  is  in  the  bladder.  If  urination  cannot  take  place  spon- 
taneously, it  must  be  drawn  off  by  a  catheter.  The  thighs,  abdomen, 
and  external  genitals  should  be  thoroughly  washed  with  soap  and 
water,  followed  by  one  of  the  antiseptics  before  named.  The  hair 
about  the  pubic  region  should  be  shaved  off  or  at  least  clipped  short. 
Following  the  cleansing  the  patient  should  wear  a  sterile  vulvar  pad 
kept  in  place  by  a  2"  binder.  If  there  has  previously  been  a  vaginal 
discharge  during  pregnancy  the  vagina  may  be  swabbed  out  with  green 
soap  followed  by  a  copious  douche  of  bichlorid  i :  5,000,  lysol  2  per 
cent,  or  salt  solution.  In  a  case  with  no  vaginal  discharge  douches 
should  not  be  used.  Before  proceeding  to  the  vaginal  examination, 
the  fetus  may  be  outlined  by  external  palpation.  As  few  internal 
examinations  as  possible  should  be  made.  It  is  well  to  have  the 
patient  walking  about  during  this  stage.  Simple  food  may  be 
allowed. 

How  should  the  hands  of  the  obstetrician  be  prepared  before 
examining  a  woman  ? 

The  hands  and  arms  to  the  elbow  should  be  first  washed  thor- 
oughly with  soap  and  warm  water,  then  rinsed  in  clear  sterile  water; 
secondly  in  a  solution  of  bichlorid  of  mercury  i :  2000,  creolin  2 
per  cent.,  or  other  equally  efficient  antiseptic  solution.  The  obstet- 
rician should  carefully  scrub  his  hands  and  nails  with  a  nail  brush 
while  using  both  the  soap  and  water  and  the  antiseptic  solution. 
Sterilized  rubber  gauntlet  gloves  are  frequently  employed  to  cover 
the  hands.  The  obstetrician  should  not  go  directly  from  a  post- 
mortem or  any  case  of  contagious  disease  to  the  lying-in  room. 


LABOR  109 

« 
How  should  an  examination  be  made  ? 

Place  the  patient  on  her  back,  with  the  knees  drawn  up,  or  on 
her  side  with  her  face  turned  from  the  examiner.  Anoint  the  index 
and  middle  fingers  with  fresh  sterile  vaselin,  and  introduce  into 
the  vagina,  passing  the  hand  under  the  thigh  until  the  vulva  is 
reached.  Introdjice  the  index  finger  alone  at  first;  if  necessary, 
the  middle  finger  may  be  added,  which  will  give  an  additional  reach 
of  about  I  inch. 

What  should  be  learned  from  the  first  examination  ? 

1 .  If  the  woman  is  pregnant. 

2.  If  she  is  in  labor. 

3.  The  condition  of  the  os  uteri,  as  to  dilatation  and  dilatability. 

4.  The  state  of  the  membranes,  and  existence  or  not  of  a  bag  of 
waters. 

5.  The  presentation  and  position  of  the  child. 

6.  The  condition  of  the  soft  parts  generally,   as  to   temperature, 
moisture,  and  dilatability. 

7.  The  size  of  the  pelvis. 

How  frequently  should  examinations  be  made? 

Often  enough  to  keep  informed  as  to  the  progress  of  the  labor. 
As  this  will  vary  greatly  in  different  cases,  no  rule  can  be  made. 
Usually,  it  is  proper  to  examine  every  hour  during  the  first 
stage.  Meantime  the  physician  need  not  be  in  the  room,  unless 
to  encourage  the  patient;  but  may  be  in  an  adjoining  room, 
or  even  absent  himself  from  the  house.  When  the  second  stage 
begins,  his  place  is  by  the  bedside.  If  progress  is  slow,  examina- 
tion may  be  made  as  in  the  first  stage;  if  rapid,  the  finger  placed  on 
the  perineum  during  a  pain  will  warn  him  as  to  the  approach  of  the 
end. 

How  should  the  bed  be  prepared? 

If  a  bed  can  be  particularly  selected,  it  should  be  narrow  and 
not  too  low.  It  should  be  so  placed  as  to  allow  easy  access  from 
both  sides.  The  bedding  should  consist  of  a  hair  mattress  or  a 
straw  paillasse.  Feather  beds  should  not  be  used  over  the  mat- 
tress. The  mattress  should  be  covered  by  a  rubber  sheet  pinned 
down  at  the  four  corners  and  over  this  a  sterilized  sheet.  On  the 
sheet  and  under  the  woman's  hips  should  be  placed  a  pad  com- 
posed of  cotton  batting  or  nursery  cloth  or  clean  paper  covered 
8 


no  COMPEND    OF   OBSTETRICS 

with  sterilized  cheese  cloth.  Many  obstetricians  use  a  Kelly's  pad. 
After  the  labor  the  Kelley's  pad  and  the  pad  under  it  are  removed 
and  a  clean  gauze-covered  pad  is  placed  upon  the  mattress,  under 
the  patient,  to  prevent  the  bed  from  being  soiled  by  the  discharges. 

When  should  the  woman  be  placed  in  bed? 

There  is  no  special  need  until  the  os  is  nearly  dilated,  unless  the 
labor  is  tedious,  when  her  strength  will  be  conserved  by  lying  down 
and  keeping  quiet. 

What  preparations  should  be  made  for  the  infant? 

Its  clothing  should  be  made  ready  and  aired.  Several  ligatures 
for  the  funis  and  a  pair  of  scissors  should  be  provided.  Both  hot 
and  cold  boiled  water  should  be  in  readiness. 

What  hygienic  measures  are  to  be  carried  out? 

1.  To  see  that  the  bowels  are  moved  by  an  enema,'  if  there  has  not 
been  a  recent  passage. 

2.  To  require  the  woman  to  urinate  occasionally. 

3.  If  thirsty,  give  her  water  to  drink. 

4.  See  that  the  room  is  properly  ventilated. 

5.  If  there  is  any  deviation  from  the  normal  course  of  labor,  ascer- 
tain and  remove  it  by  appropriate  treatment. 

What  things  are  to  be  prevented? 

Crowding  the  room  by  unnecessary  company.  Meddlesome 
practices  of  old  women,  such  as  giving  "teas,"  and  in  general  any- 
thing that  will  disturb  the  woman,  mentally  or  physically. 

What  objections  to  giving  anesthetics  to  make  the  labor  painless 
are  urged  by  those  who  oppose  this  practice? 

1.  The  pain  is  not  great,  unless  some  abnormal  condition  is  present, 
which  should  be  sought  for  and  treated. 

2.  Natural  labor  lasts  but  a  short  time.  • 

3.  Anesthetics  protract  the  labor. 

4.  They  increase  the  risk  of  post-partum  hemorrhage. 

5.  From  the  same  cause  (imperfect  contraction  of  the  womb)  they 
increase  the  liability  to  all  the  puerperal  diseases. 

6.  They  endanger  the  child's  life  (especially  chloroform). 

How  are  these  objections    met    by  the  advocates    of    obstetric 
anesthesia? 
I.  The  proper  administration  of  an  anesthetic  during  labor  renders 


LABOR  III 

the  act  painless,  and  prevents  the  exhaustion  which  may  follow 
the  protracted  suffering,  often  severe. 

2.  It  is  not  proved  that,  when  properly  administered,  they  protract 
the  labor  or  increase  the  risk  of  hemorrhage,  and  even  granting 
the  latter  objection,  this  risk  can  be  overcome  by  careful  man- 
agement of  the  third  stage  of  labor  and  the  use  of  ergot. 

3.  If  rightly  administered  in  suitable  cases,  the  danger  to  the  mother 
and  child  is  not  increased. 

4.  It  prevents  the  sudden  expulsion  of  the  child  and  consequent 
violent  tearing  of  the  perineum. 

When  may  an  anesthetic  be  used  in  normal  labor? 

During  the  second  stage  of  labor,  when  the  pain  is  severe,  as 
when  the  head  is  passing  through  the  os  uteri  or  vulval  orifice,  pro- 
vided no  condition  exists  which  would  be  considered  a  contraindica- 
tion to  etherization  for  surgical  purposes,  and  provided  the  uterine 
contractions  are  of  normal  intensity. 

How  should  an  anesthetic  be  given? 

As  the  object  in  view  is  to  deaden  the  pain,  not  to  produce  un- 
consciousness, the  ether  or  chloroform  should  be  given  in  small 
quantities,  inhaled  only  during  the  pains  and  withdrawn  in  the 
intervals  between  them.  In  the  last  stage  of  labor,  while  the  fetal 
head  is  passing  over  the  perineum,  it  is  generally  best  to  increase 
the  amount  of  anesthetic  producing  for  a  moment  complete  uncon- 
sciousness. 

What  anesthetic  is  to  be  preferred? 

1.  Chloroform  is  most  generally  used,  because  it  is  quicker  in  its 
action,  more  pleasant  to  take,  and  less  is  required  to  produce  the 
effect  for  which  it  was  given  nitrous  oxid  is  also  occasionally  used. 

2.  Ether  is  probably  safer,  and  appears  to  be  less  likely  to  enfeeble 
uterine  contractions. 

What  disturbances  often  attend  the  end  of  the  first  stage? 

1.  The  woman  is  very  apt  to  vomit,  which  relaxes  and  prepares 
the  soft  parts  and  increases  the  uterine  contractions.     | 

2.  A  rigor  sometimes  occurs,  temporarily  suspending  labor,  but 
with  hot  applications  to  the  feet  and  a  hot  drink,  it  usually  speedily 
ceases. 

What  duties  are  required  during  the  second  stage? 
I.  To  rupture  the  membranes,  if  this  does  not  occur  spontaneously. 


112  COMPEND    OF    OBSTETRICS 

2.  To  observe  the  descent  of  the  child,  and  to  be  ready  to  remedy 
any  departure  from  the  normal  course. 

3.  To  prevent  the  laceration  of  the  perineum. 

4.  To  complete  the  delivery  of  the  child. 

How  should  the  patient  be  treated  during  this  stage? 

It  is  best  that  she  should  be  in  bed  and  covered  only  by  a  sheet 
or  blanket  during  the  entire  second  stage.  She  should  lie  on  her 
side  with  her  back  toward  the  attending  physician,  her  night  dress 
well  drawn  up  under  the  arms.  A  nurse  should  support  the  upper 
thigh,  or  a  stout  pillow  may  be  placed  between  the  knees.  A  sheet 
might  weU  be  attached  to  the  head  of  the  bed  and  given  to  her  to 
pull  upon  during  a  pain.  The  lateral  position  makes  perineal  rupture 
more  difi&cult  and  makes  the  examination  much  easier.  Vaginal 
examinations  will  be  more  frequently  necessary  in  the  second  stage 
than  during  the  first;  they  should  be  made  often  enough  to 
follow  accurately  the  position  of  the  presenting  part  in  its  course 
along  the  birth  canal. 

How  are  the  membranes  to  be  ruptured? 

By  pressing  the  finger  against  them  while  they  are  made  tense  by  a 
contraction.  If  they  are  too  thick  and  strong  to  yield  to  this,  the  nail 
of  the  middle  finger  may  be  prepared  as  follows :  First,  make  a  straight 
cut  in  the  free  border  of  the  nail  and  in  the  middle  Une  of  the  finger. 
Second,  pare  away  the  free  border  on  one  side  of  the  cut,  which  will 
have  a  sharp,  knife-like  edge. 

If  the  bag  of  waters  is  large,  it  is  well  to  place  pads  of  sterile  cheese 
cloth  or  well  boiled  old  linen,  etc.,  in  front  of  the  vulva  before  ruptur- 
ing, in  order  to  soak  up  the  Hquor  amnii  when  discharged. 

What  occurrences  often  attend  the  end  of  the  second  stage? 

1.  The  woman  has  a  sensation  of  wanting  to  move  the  bowels  fre- 
quently and  will  ask  to  sit  up  or  to  be  placed  on  a  commode.  This 
feeHng  is  caused  by  the  pressure  of  the  child's  head  on  the  bowel. 
Of  course,  she  is  not  to  be  allowed  to  sit  up  at  this  time. 

2.  Cramps  in  the  leg  often  occur  from  pressure  of  the  descending 
head  against  the  sciatic  nerve.     Rubbing  the  leg  affords  relief. 

How  is  the  perineum  to  be  guarded? 

The  obstetrician,  sitting  beside  the  patient,  should  have  before 
him  a  basin  containing  a  solution  of  bichlorid  of  mercury  1:5000, 
or  other  efficient  antiseptic  solution,  in  which  smaU  pieces  of  cotton 


LABOR  113 

or  gauze  have  been  placed.  With  one  hand  under  the  upper  thigh,  he, 
with  the  thumb  on  the  occiput  and  the  fingers  on  the  anterior  part  of 
the  fetal  head,  guides  it  away  from  the  perineum  or  holds  it  back  during 
a  pain;  the  other  hand,  placed  against  the  perineum,  should  gently  and 
steadily  press  from  the  sides  toward  the  center  and  upward  toward 
the  symphysis;  or  by  bringing  out  the  head  in  the  absence  of  a  pain,  if 
possible.  When  the  head  gently  distends  the  perineum  and  a  part 
of  the  occiput  protrudes,  pass  two  fingers  into  the  rectum,  and  place 
them  on  the  brow,  malar  bones,  or  chin  of  the  child,  as  may  be 
convenient.  Place  the  thumb  on  the  occiput.  The  head  may  then 
be  controlled  and  prevented  from  passing  through  the  vulva  during  a 
pain.  If,  when  a  pain  has  subsided,  the  head  be  now  pushed  over  the 
perineum,  laceration  will  be  prevented.  It  is  also  necessary  that  the 
woman  shall  not  bear  down  at  this  time.  Anesthesia  should  be 
complete  as  the  head  passes  over  the  perineum. 

What  is  episiotomy? 

An  operation   designed  to   save  the  perineum,  by  making  small 
incisions  into  its  margin,  on  either  side  of  the  median  line. 

What  is  to  be  done  when  the  head  is  bom? 

1.  Ascertain  if  the  funis  is  around  the  child's  neck,  and,  if  so,  un- 
wind it. 

2.  If  no  uterine  contraction  appears  to  be  forthcoming  pass  a  finger 
into  the  vagina,  below  the  child's  neck,  and,  hooking  it  into  the 
posterior  axilla,  withdraw  the  child,  taking  care  that  the  shoulders 
do  not  lacerate  the  perineum. 

What  is  the  first  attention  to  be  rendered  to  the  child? 

1 .  Pass  a  finger  covered  by  sterile  gauze  into  its  mouth  to  remove  any 
mucus  which  may  be  there. 

2.  It  if  does  not  at  once  cry,  let  it  hang  head  downward  for  a  moment; 
give  it  a  slight  spank  on  the  buttocks,  dash  a  small  quantity  of  cold 
water  on  it;  all  mucus  should  be  carefully  removed  from  the  child's 
mouth  by  small  pieces  of  gauze  dipped  in  a  saturated  solution  of 
boric  acid,  or  use  other  means  of  resuscitation  until^it  gives  a  good 
cry. 

3.  When  it  has  cried  well,  tie  the  cord. 

How  is  the  cord  tied? 

A  ligature  of  several  strands  of  sewing  thread  or  other  material 
should  be  tied  two  or  three  finger-breadths  from  the  child's  navel. 
A  second  ligature  should  be  applied  several  inches  from  this,  and  the 
cord  cut  between  the  ligatures  with  scissors.     If  there  is  much  Whar- 


114  COMPEND    OF    OBSTETRICS 

ton's  gelatin  in  the  cord,  it  is  well  to  hold  it  firmly  at  the  navel,  and 
endeavor  with  the  finger  and  thumb  to  squeeze  out  the  gelatin  or 
"strip"  the  cord.  After  cutting  the  cord  see  that  the  ligature  is  firm, 
and  that  no  blood  is  escaping,  and  hand  the  child  to  the  nurse. 

How  is  the  cord  to  be  dressed? 

The  physician  is  usually  expected  to  dress  the  stump  of  the  cord 
attached  to  the  child.  Take  a  piece  of  aseptic  gauze,  about  4  inches 
square;  cut  a  hole  in  the  middle  large  enough  for  the  cord  to  pass 
through ;  sHp  it  over  the  stump  and  fold  it  so  as  to  thoroughly  cover  it. 
It  is  a  good  practice  to  dust  the  cord  stump  with  an  aseptic  powder, 
such  as  salicylic  acid  5ss,  boracic  acid  §j. 

What  attentions  are  to  be  rendered  to  the  woman? 

1.  The  placenta  is  to  be  delivered  after  the  method  of  Cred^  {vide 
p.  106). 

2.  An  inter-vaginal  douche  of  one  gallon  of  solution  of  bichloride  of 
mercury  1:5000,  creolin  or  lysol  i  per  cent.,  normal  salt  solution 
other  antiseptic  solutions  should  be  given. 

3.  The  soiled  clothing  is  to  be  removed  and  a  sterile  pad  placed  at 
the  vulva  to  receive  the  discharges. 

4.  A  broad  bandage  or  "binder"  should  be  applied  around  the 
abdomen. 

5.  The  uterus  should  occasionally  be  felt  through  the  abdominal  walls, 
to  be  sure  it  remains  contracted. 

What  is  the  position  of  the  womb  after  delivery? 

Just  after  the  deUvery  of  the  placenta  the  womb  should  be  in 
the  hypogastrium,  its  fundus  reaching  half  way  to  the  umbiHcus, 
and  feeling  as  hard  as  stone.  In  a  short  time  (generally  within 
the  hour),  the  abdominal  muscles  regain  their  tonicity,  and  the 
"retentive  power  of  the  abdomen"  draws  the  womb  upward,  its 
fundus  reaching  nearly  or  quite  to  the  umbilicus. 

Why  does  a  rigor  often  occur  just  after  labor? 

1.  The  bedding  and  clothes  are  apt  to  be  wet  with  the  discharges. 

2.  The  withdrawal  of  the  child  takes  away  a  source  of  bodily  heat, 
its  temperature  being  nearly  a  degree  higher  than  that  of  the 
mother. 

When  may  the  physician  leave,  and  when  should  he  return? 

He  may  leave  within  half  an  hour,  if  the  woman  has  been  cared 
for  as  above,  and  is  in  good  condition.     He  shoiild  return  within 


LABOR  115 

from  twelve  to  twenty -four  hours;  and  in  general  those  who  watch 
their  patients  best  will  have  the  least  trouble. 

What  should  a  physician  carry  with  him  in  attending  an  obstetric 
case? 

A  physician's  obstetric  bag  should  contain  the  following: 

1.  A  good  copper  sterilizer,  either  nickel  plated  or  plain,  and  this 
may  conveniently  be  arranged  in  two  divisions,  one  fitting  into 
the  other,  and  acting  as  a  lid.  When  open  and  in  use  one  has 
thereby  two  sterilizers  in  which  the  instrument  may  be  laid  out 
and  sterilized  by  boiling. 

2.  One  or  preferably  two  pairs  of  obstetric  forceps  each  with  an 
axis  traction  attachment. 

3.  Two  pairs  of  fairly  long  clamp  forceps  for  clamping  the  um- 
bilical cord.  Special  forceps  are  made  for  this  purpose,  but  the 
ordinary  broad  ligament  forceps  will  do  very  well. 

4.  Six  pairs  of.  hemostats. 

5.  Umbilical  scissors. 

6.  Volsellum  or  double  tenaculum  forceps,  and  one  pair  uterine 
dressing  forceps. 

7.  Curved  needles  of  various  sizes  and  a  needle  holder. 

8.  Silk-worm  gut,  chromic  catgut  and  silk  suture  material. 

9.  Rubber  apron,  sterilized  operating  gown  or  an  operating  suit  in 
a  canvas  bag. 

10.  Rubber  gloves,  sterilized. 

11.  Kelly  pad. 

12.  Four-quart  fountain  syringe  with  proper  vaginal  douche  tubes. 

13.  Nail  brush,  and  soap. 

14.  Bichlorid  of  mercury  tablets. 

15.  Catheters  of  rubber  and  glass. 

16.  Boric  acid  in  powder. 

17.  Proper  solution  of  silver  nitrate  for  the  child's  eyes  and  an  eye 
dropper. 

18.  Sterilized  gauze  in  small  packages. 

19.  Absorbent  cotton. 

20.  Hypodermatic  syringe  and  a  good  selection  of  tablets;  strych- 
nin, atropin,  ergot,  and  morphia  should  always  be  included. 

21.  Tape  for  umbilical  cord. 

22.  Small  scales  for  weighing  baby. 

23.  To  this  list   may   be   added   those   instruments   necessary  for 
Cesarean  section  or  craniotomy.     (See  articles  on  these  subjects.) 


Il6  COMPEND    OF    OBSTETRICS 

24.  Ether  and  chloroform. 

25.  One  pair  vaginal  retractors. 

26.  Scalpel,  tenaculum. 

27.  Saline  transfusion  apparatus. 

28.  Intra -uterine  douche  tube. 

What  articles  should  a  woman  prepare  for  herself  before  labor? 

Three  abdominal  binders,  12  inches  wide  and  48  inches  long, 
made  from  two  thicknesses  of  good  strong  muslin. 

Three  breast  binders  about  8  inches  wide,  and  long  enough  to 
go  around  the  body  on  a  level  with  the  breasts. 

One  piece  of  rubber  sheet  or  white  oilcloth  as  wide  as  the  bed 
and  half  as  long. 

Three  pads  as  wide  as  the  bed  and  half  as  long,  made  of  four 
or  five  thicknesses  of  newspaper,  clean  old  muslin,  absorbent  cotton 
or  cotton  lining  covered  with  cheese  cloth.  Nursery  cloth  is  most 
commonly  used. 

One  fountain  syringe,  2  quarts. 

Two  dozen  vulvar  pads,  10  inches  long,  3  inches  wide  and  i  inch 
thick,  made  of  cotton  batting  covered  with  cheese  cloth.  The 
covering  must  extend  beyond  the  ends  of  the  cotton  for  about  4 
inches  at  each  end.  These,  with  the  bed  pads,  must  be  rendered 
aseptic  by  soaking  in  a  solution  of  bichlorid  i  :  1000,  and  drying  in 
an  oven  or  sterilizer  or  by  sterilization  with  dry  heat. 

Several  strips  of  clean  old  muslin. 

One  yard  of  sterile  borated  gauze  in  a  sealed  bottle. 

One  medium-sized  roll  of  sterile  absorbent  cotton. 

One  dozen  each  of  large  and  small  safety  pins. 

A  bottle  of  carbolized  vaselin. 

Some  whisky  or  brandy;  a  quantity  of  hot  and  cold  boiled  water. 

One  bed  pan. 

What  articles  should  be  prepared  for  the  child? 

Four  to  6  dozen  diapers.* 

Four  to  6  pairs  knit  (woolen)  socks. 

Three  or  4  woolen  shirts. 

Four  flannel  night  shirts. 

Four  flannel  day  shirts.       ^  Skirts  to  be  made  with  waists  instead 

Four  to  6Vhite  day  skirts.  J       of  bands. 

Six  to  10  slips. 

Six  to  10  dresses. 

•  Hirst's  "Text-book  of  Obstetrics." 


LABOR  117 

Material  for  4  or  5  flannel  bands  (45-  to  50-cent  flannel). 

Soft' pillow  (good  size  14  X  18  inches). 

Soft  pillow  covers. 

Knit  wrapping  blankets. 

Sacques,  wrappers,  bibs,  caps,  blankets,  veils,  etc. 

What  directions  would  you  give  a  nurse  regarding  the  care  of  a 
patient  after  normal  labor? 

All  directions  should  be  given  in  writing. 
Hirst's  directions  are  as  follows: 

FOR  THE   MOTHER 

The  temperature  should  be  taken  thrice  daily — morning,  noon, 
and  evening. 

Vaginal  douches  should  not  be  used  after  normal  labor. 

Place  a  pad  of  nursery  cloth  under  the  patient,  changing  it  when 
soiled. 

With  aspetic  hands,  an  occlusion  bandage  consisting  of  salicy- 
lated  cotton  and  carbolized  gauze  should  be  made,  and  is  to  be 
changed  every  four  hours  for  the  first  five  days. 

The  external  genitalia  are  to  be  washed  off  every  five  or  six  hours 
with  a  warm  solution  of  corrosive  sublimate  i :  4000,  using  absorbent 
cotton  for  the  purpose. 

The  bladder  is  to  be  emptied  by  the  catheter  three  times  a  day  if 
necessary. 

The  patient  is  to  lie  on  her  back;  she  may  be  moved  from  one 
side  of  the  bed  to  the  other  several  times  a  day;  her  limbs  may  be 
rubbed  with  alcohol  and  water  or  bathing  whisky  once  a  day. 

The  nurse's  hands  are  to  be  washed  with  a  nail-brush,  soap,  and 
water,  and  rinsed  in  a  i :  3000   corrosive   sublimate  solution  before 
catheterizing  the  patient  or  cleansing  the  genitals  or  breasts. 
Diet: 

First  forty-eight  hours. — One  and  one-half  to  two  pints  of  milk 
a  day,  gruel  soup,  one  cup  of  tea  a  day,  toast  and  butter. 

Second  forty-eight  hours. — Milk,  toast,  poached  eggs,  porridge 
soup,  corn  starch,  wine-jelly,  tapioca,  small  raw  or  stewed 
oysters,  one  cup  of  tea  or  coffee  a  day. 

Third  forty-eight  hours. — Soup,  mashed  potatoes,  white  meat 
of  fowl,  beets,  in  addition  to  above. 

After  the  sixth  day  return  cautiously  to  ordinary  diet.  Three 
meals  daily,  meat  of  an  easily  digested  character  at  one  of  them 
— white  meat  of  fowl,  tenderloin,  etc. 


Il8  COMPEND    OF    OBSTETRICS 

Take  a  glass  of  milk  at  least  three  times  a  day  before  meals  and 
before  going  to  sleep  at  night;  also  a  glass  at  midnight. 

FOR   THE    CHILD 

Rub  the  cliild  well  with  sweet  oil,  and  then  wash  it  on  the  nurse's 
lap.  The  bath-tub  may  be  used  at  the  end  of  the  first  week,  the 
water  not  being  over  ioo°  F. 

Dress  the  cord  with  salicylated  cotton.  Look  carefully  if  there  is 
any  bleeding.  A  dusting  powder  for  the  navel  is  salicyhcacid  i  part 
and  starch  5  parts. 

The  child  should  be  bathed  daily  with  water,  Castile  soap,  and  a 
soft  sponge,  in  the  warmest  part  of  the  room.     Avoid  the  eyes. 

Change  diapers  often.  For  chafing  use  cold  cream  and  talcum 
powder. 

The  child  is  to  be  nursed  at  the  breast  every  four  hours  for  the 
first  two  days.     No  other  food  is  to  be  given  it. 

After  the  second  day  it  should  be  nursed  every  two  hours,  from 
7  A.  M.  to  9  P.  M.,  and  twice  during  the  night. 

After  every  nursing  the  nipples  are  to  be  carefully  dried  and  then 
smeared  with  a  little  sweet  oil  for  the  first  week  or  two,  applied  with 
fresh  pledgets  of  absorbent  cotton. 

What  are  after-pains? 

The  pain  sometimes  experienced  after  labor,  due  to  the  contractions 
of  the  uterus.  They  are  rarely  felt  by  primiparae,  and  usually  increase 
in  severity  with  each  subsequent  labor.  They  may  occur  only  a  few 
times,  or  may  keep  up  for  several  days.  If  severe  enough  to  need 
treatment,  opium  and  camphor,  in  powder  or  as  in  paregoric,  will  be 
the  proper  remedy. 

What  is  the  caput  succedaneum? 

An  edematous  swelb'ng  formed  on  the  part  of  the  presentation  in 
advance,  caused  by  the  pressure  upon  the  circulation  in  the  presenting 
circumference  by  the  grip  of  the  cervix,  vagina,  and  pelvic  walls.  It 
forms  only  when  the  head  is  arrested  at  any  point  for  some  time. 

How  long  does  it  remain? 

For  several  days  after  birth,  if  not  interfered  with. 

THE  MECHANISM  OF  LABOR 

What  is  meant  by  the  mechanism  of  labor? 

The  purely  mechanical  movements  involved  in  the  passage  of  the 


THE    MECHANISM   OF    LABOR 


119 


child  through  the  pelvis,  in  distinction  to  the  vital  and  clinical  condi- 
tions connected  with  the  process. 

"With  what  is  the  mechanism  of  labor  concerned? 

With  three  things: 

1.  The  body  to  be  propelled. 

2.  The  tube  through  which  it  is  propelled,  and 

3.  The  propelling  force. 

What  is  the  propelling  or  motive  force  in  labor? 

1.  The  contractions  of  the  uterus,  principally,  aided  by: 

2.  The  contractions  of  the  abdominal  muscles. 

3.  The  elastic  resistance  of  the  perineum. 

When  is  the  first  or  uterine  force  exerted? 

Throughout  the  entire  labor,  and  is  the  main  and  necessary  force. 

When  is  the  second  or  abdominal  force  exerted? 

It  may  be  voluntarily  exercised^at  any  time,  but  usually  is  reflexly 
excited  when  the  head  is  low 
in   the    pelvis  becoming  al- 
most involuntary. 

What  effect  has  the   ab- 
dominal force? 

1.  It  aids  the  uterine  force 
■directly,  by  pushing  the 

child  onward,  and — 

2.  Indirectly,  by  holding 
the  womb  down  and 
preventing  it  from  being 
pushed  upward  by  the 
pelvic  resistance  to  the 
passage  of  the  child. 


When  and  how  is  the 
perineal  force  exerted? 

After  the  child  has 
reached  the  outlet,  it  can  go 
no  further  without  passing 
through  or  over  the  perineum 


Fig.  43. — A.  Perineum.  B.  The  direction 
of  the  uterine  force.  C.  The  direction  of  the 
perineal  force.  D.  The  resultant  of  the  two 
forces,  in  which  the  head  moves. 


The  uterine  force  is  unable  to  propel 
it  in  any  direction  except  against  or  through  the  perineum.  A  new 
force  is  therefore  provided  in  the  elastic  resistance  of  the  perineum, 
which  tends  to  push  the  head  back  in  nearly  the  opposite  direction 


I20 


COMPEND    OF    OBSTETRICS 


(a  little  forward  as  well).     Therefore  the  head  moves  in  the  resultant  of 
the  two  forces,  and  over  the  perineum. 

What  form  does  the  child  assume  in  its  intrauterine  growth? 

It  is  substantially  an  ovoid,  or  egg-shaped  figure,  the  extremities 
being  flexed  and  pressed  against  the  trunk. 

What  relations  may  it  assume  to  the  pelvic  inlet? 

Either  end  (the  head  or  breech)  may  be  opposite  the  inlet,  or  it  may 
lie  transversely  across  it. 

What  is  the  presentation  of  the  child? 

The  part  of  the  child  in  advance,  or,  more  accurately,  that  part  of 
the  child  included  within  the  circumference  of  the  inlet  at  the  beginning 
of  labor. 

How  many  presentations  are  there? 

Four: 

I.  The  vertex. 
II.  The  face. 

III.  The  breech. 

IV.  Transverse. 

Which  is  the  most  common? 

The  vertex  presents  in  over  90  per  cent,  of  all  labors. 

What  distinguishing  marks  exist  upon  the  head? 

I.  Sutures.     II.  Fontanelles.     III.  Protuberances. 

.  The  sagittal  suture  and  its  continuation,  the  bi-frontal, 
extend  antero-posteriorly  between  the  parietal  and 
frontal  bones. 
I.  u  2.  The  lambdoidal  suture  extends  from  the  posterior  limit 
of  the  sagittal  suture  between  the  occipital  and  parietal 
bones,  making  a  V-shaped  Hne. 
3.  The  coronal  suture  extends  between  the  parietal  and 
frontal  bones,  crossing  the  sagittal  at  right  angles. 

I.  The  posterior  fontanelle,  a  small,  triangular  enlargement 

of  the  sutural  membrane,  at  the  junction  of  the  sagittal 

and  lambdoidal  sutures. 
II.  '^       2.  The  anterior  fontanelle,  a  large  quadrilateral  enlargement 

of  the  sutural  membrane,  at  the  junction  of  the  sagittal 

and  coronal  sutures. 
3.  The  postero-lateral  fontanelles,  one  on  each  side,  at  the 

inferior  limits  of  the  lambdoidal  suture. 


(U 

■<-» 
CO 


a 
a 

a 
o 


THE   MECHANISM   OF   LABOR 


121 


III. 


O 

a 

M 

:=( 

■M 

o 
l-l 

Q-1 


1.  The    parietal    protuberances,    called    also    eminences    or 
bosses,  situated  in  the  center  of  each  parietal  bone. 

2.  The  jrontal  protuberances,  situated  at  the  sides  of  the 
frontal  bones. 

3.  The   occipital  protuberance,   situated   in   the   center   of 
the  accipital  bone. 


What  is  the  object  of  the  sutures  and  fontanelles? 

They  admit  of  the  mobility  and  overlapping  of  the  bones,  so  as 
to- diminish  the  size  of  the  head  in  labor.  Incidentally  they  fur- 
nish us  with  important  "landmarks."  The  overlapping  edge  of 
bone  is  usually  felt,  rather  than  the  suture  itself. 

What  are  the  diameters  and  planes  of  the  fetal  head? 

The  diameters  are  lines  drawn  from  one  point  to  another;  the 
planes  are  imaginary  levels  drawn  transversely  through  different 
points  of  the  head,  each  for  the  purpose  of  facilitating  the  descrip- 
tion of  the  relation  of  the  head  to  the  pelvis  in  labor. 

Name  the  diameters  and  planes. 

1.  The  occipito-mental  diameter,  drawn  from  the  highest 
point  of  the  occiput  to  the  point  of  the  chin,  and  meas- 
ures 51/4  inches,  or  13  1/2  cm. 

2.  The  occipito-frontalf  from  the  occiput  to  the  root  of 
the  nose,  about  41/2  inches,  or  11  1/2  cm. 

3.  Suh-occipito-hregmatiCy  drawn  from  the  junction  of 
the  occiput  with  the  neck  to  the  point  of  intersection 
in  the  large  fontanelle  of  the  coronal  and  sagittal  suture, 
33/4  inches,  or  9  1/2  cm. 

4.  Fronto-mental  extends  from  the  top  of  the  forehead 
to  the  point  of  the  chin,  31/4  inches,  or  8  1/2  cm. 

5.  Cervico-bregmatic,  from  the  middle  of  the  large  fon- 
tanelle  to  the  upper  part  of  the  neck  near  the  larynx, 
3  3/4  inches,  or  9  1/2  cm. 

6.  The  cervico-frontal  diameter,  drawn  from  the  apex  of  the 
forehead  to  the  occipital  ridge  or  nape  of  the  neck, 
and  measures  a  little  less  than  4  inches,  or  4  —  inches, 
or  10  cm. 

7.  The  bi-parietal  or  transverse  diameter,  drawn  from 
one  parietal  protuberance  to  the  other,  and  measures 
33/4  inches,  or  9  1/2  cm. 


122 


COMPEND    OF    OBSTETRICS 


X/i 


8.  Bi-temporal,  between  the  extremities  of  the  coronal 
sutures,  31/4  inches,  or  8  1/2  cm. 

9.  Bi-mastoid,  between  the  mastoid  processes  at  the  base 
of  the  skull,  3  inches,  or  7  1/2  cm. 

1.  The  occipito-frontal  plane,  drawn  transversely  through 
the  occipito-frontal  diameter  (or  through  the  occipital 
and  frontal  protuberances) ;  when  the  head  is  neither 
flexed  nor  extended  (the  body  being  erect),  this  plane 
is  exactly  horizontal  (corresponds  to  the  plane  of  the 
horizon). 

2.  The  cervico-frontal  plane,  drawn  transversely  through 
the  cervico-frontal  diameter.  When  the  head  is  half 
flexed,  this  plane  is  horizontal,  and  therefore  may  be 
called  the  plane  of  demi-flexion. 

3.  The  cervico-bregmatic  plane,  drawn  transversely  through 
the  cervico-bregmatic  diameter.  When  the  head  is 
completely  flexed,  this  plane  is  horizontal,  and  therefore 
may  be  called  the  plane  of  complete  flexion. 


Occipito-mental. 


Sub-occipito-bregmatic 


Fronto-mental. 


Occipital -front  al . 


Cervico-bregmatic. 


Fig.  44. — Antero-posterior  and  Vertical  Diameters  of  the  Fetal  Head. — 

{Tarnier.) 


What  outline  is  intercepted  by  these  planes? 

In  the  occipito-frontal,  an  elliptical  outline;  long  diameter  4  1/2 
inches.     Transverse  diameter  33/4  inches. 

In  the  cervico-frontal,  an  elliptical  outline;  long  diameter  4  — 
inches.     Transverse  diameter  33/4  inches. 

In  the  cervico-bregmatic,  a  circular  outline;  long  diameter  3  3/4 
inches.     Transverse  diameter  33/4  inches. 


THE    MECHANISM    OF    LABOR  1 23 

What,  important  deduction  may  be  drawn  from  these  facts? 

The  more  the  head  is  flexed,  the  smaller  is  the  outline  presented. 

What  is  the  circumference  of  the  fetal  head? 

The  circumference  of  the  head  from  the  chin  to  the  vertex,  using 
the  latter  term  to  express  the  highest  part  of  the  skull,  without  refer- 
ence to  any  fixed"  anatomical  point,  is  about  14  3/4  inches,  or  37  1/2 
cm.  The  circumference  at  the  sub-occipito-bregmatic  diameter  is  but 
13  inches,  or  33  cm.     (Lusk.) 

Name  the  important  diameters  of  the  fetal  trunk? 

The  bis-acromial  4.7  inches — about  12.75  cm.  Is  capable  of  com- 
pression.    Bis-trochanteric,  3.5  inches,  or  9  cm. 

In  how  many  ways  may  the  vertex  enter  the  pelvis? 

The  elliptical  outline  of  the  head  may  enter  with  the  occiput  in 
front  and  to  the  left  or  right,  i.e.,  in  relation  with  the  ilio-pectineal 
eminences  of  either  side,  and  behind  and  to  the  right  or  left,  i.e., 
in  relation  with  the  sacro-iliac  joint  of  either  side.  There  are, 
therefore,  four  positions  of  the  vertex,  named  as  follows: 

1.  Left  Occipito- Anterior. 

2.  Right  Occipito- Anterior. 

3.  Right  Occipito-Posterior. 

4.  Left  Occipito-Posterior. 

What  is   position? 

Position  is  the  relation  which  the  presenting  part  of  the  fetus 
bears  to  the  four  cardinal  points  on  the  pelvic  inlet,  i.e.,  the  sacro- 
iliac joints  and  the  pectineal  eminences. 

How  many  positions  are  there  of  the  Face  presentation? 

Since  the  face  has  also  an  elliptical  outline,  with  the  mentum  or 
chin  at  one  end  in  relation  with  the  sacro-iliac  joints  or  ilio-pecti- 
neal eminences  of  either  side,  we  have  the  same  arrangement  as 
in  the  vertex,   or: 

1.  Left  Mento-Anterior. 

2.  Right    Mento-Anterior. 

3.  Right  Mento-Posterior. 

4.  Left    Mento-Posterior. 

How  many  positions  are  there  of  the  Breech  presentation? 

Since  the  breech  has  also  an  elliptical  outline,  with  the  sacrum 


124  COMPEND    OF    OBSTETRICS 

in  a  direct  line  with  the  occiput,  we  have  the  same  arrangement  as 
in  the  vertex,   or: 

1.  Left  Sacro- Anterior. 

2.  Right  Sacro- Anterior. 

3.  Right  Sacro-Posterior. 

4.  Left  Sacro-Posterior. 

How  many  positions  are  there  of  the  Transverse  presentation? 

For  the  sake  of  uniformity  we  may  assume  an  elliptical  outline 
for  the  shoulder,  with  the  dorsum,  or  back  of  the  shoulder,  as  the 
name-point.  This  gives  us  the  same  arrangement  as  in  the  other 
presentations,  or: 

1.  Left  Dorso-Anterior. 

2.  Right  Dorso-Anterior. 

3.  Right  Dorso-Posterior. 

4.  Left  Dorso-Posterior. 

How  may  the  positions  be  more  briefly  designated? 

By  initials,  as  L.  O.  A.  for  left  occipito-anterior,  R.  S.  P.  for  right 
sacro-posterior,  and  so  on. 

How  may  these  sixteen  positions  be  represented  in  a  single  scheme? 

Or  by  initials  only. 


Left 
Right 

0 
.ti   0 

0  % 

0 

0 

Posterior. 
Anterior. 

LqA. 
RcoA. 

Right 

a 
03 

0 

Anterior. 

R^'P. 

Left 

CD 

Q 

Posterior. 

LqP. 

How  is  the  head  situated  at  the  beginning  of  labor  in  the  L.  O.  A. 
position? 

The  occiput  points  to  the  left  ilio-pectineal  eminence;  the  bi-frontal 
suture  is  opposite  the  right  sacro-iliac  symphysis,  and  the  sagittal 
suture  lies  in  the  right  oblique  diameter. 

How  can  a  L.  O.  A.  position  be  diagnosticated  before  labor? 

By  palpation  the  continuous  curved  line  of  the  fetal  back  will  be 
found  on  the  left  side  and  to  the  front  of  the  mother's  abdomen. 
Above  will  be  recognized  the  breech,  while  just  above  the  pubic  bone 
the  head  can  be  felt  as  a  ball  with  a  constricted  part,  the  neck  just 
above  it.  The  heart-sounds  will  be  heard  best  midway  on  a  line 
extending  from  the  left  ilio-pectineal  eminence  to  the  point  of  inter- 


THE    MECHANISM    OF    LABOR 


125 


section  of  the  perpendicular  and  transverse  lines,  or  more  simply 
the  center  of  a  line  drawn  from  the  umbilicus  to  the  anterior-superior 
spine  of  the  ilium  on  the  left  side;  the  left  lower  uterine  quadrant. 

What  is  the  mechanism  of  delivery  in  the  L.  O.  A.  position? 

I.  Flexion   occurs,    whereby   the   cervico-frontal,    or   even   the   sub- 
occipito-bregmatic  diameter,  is  substituted  for  the  occipito-frontal. 


Fig.  46. — -Right  Occipito-anterior. 


Fig.  47. — Right  Occipito-posterior. 

thus  reducing  the  outline  presenting  in  the  pelvis.  The  head  is 
strongly  flexed  in  its  relation  to  the  body.  It  enters  the  pelvis 
usually  in  the  right  diagonal  of  the  mother's  pelvic  inlet.  Occasion- 
ally, however,  the  head  may  enter  in  the  transverse,  anterior  rota- 
tion occurring  after  it  passes  the  pelvic  brim  or  superior  strait. 


126 


COMPEND    OF    OBSTETRICS 


2.  The  head  descends  in  the  pelvis,  and  at  the  same  time  a  leveling 
movement  occurs  by  which  the  forehead  descends  more  rapidly 
than  the  occiput,  and  becomes  level  with  it. 

3.  While  the  head  descends  it  also  rotates,  so  that  the  sagittal  suture  is 
finally  brought  into  the  median  line  or  antero-posterior  diameter; 


Fig.  48. — Left  Occipito-axterior. 


Fig.  49. — Left  Occipito-posterior. 


first  of  the  pelvic  cavity,  then  of  the  outlet.      By  the  time  the  head 
reaches  the  pelvic  outlet,  the  shoulders  engage  in  the  left  diagonal  of 
the  mothers  inlet. 
4.  When  the  head  reaches  the  outlet,  the  occiput  or  nape  of  the  neck 
remains  fixed  under  the  sub-pubic  arch,  the  uterine  forces  continu- 


THE    MECHANISM    OF    LABOR  1 27 

ing  to-force  the  child  downward  along  the  birth  canal,  the  forehead 
and  face  sweep  over  the  perineum  by  a  movement  of  extension. 

5.  After  the  head  is  born  it  undergoes  a  movement  of  external  rotation, 
or  restitution,  because  the  shoulders,  entering  the  pelvic  cavity  in  the 
left  oblique  or  transverse  diameter  now  come  to  the  outlet.  They 
now  undergo  a  movement  of  internal  rotation,  so  that  the  bisacromial 
diameter  is  finally  brought  into  the  median  line  or  antero-posterior 
diameter,  the  right  shoulder  turning  under  the  pubic  symphysis 
the  left  sweeping  over  the  perineum. 

6.  The  trunk  now  pivots  upon  the  arm  just  below  the  shoulder,  and  the 
body  is  delivered  by  a  movement  of  lateral-flexion. 

What  variations  occur  in  the  mechanism  of  the  L.  O.  A.  position? 

If  there  is  not  a  close  fit  between  the  head  and  the  pelvis  there 
may  be  less  flexion  and  rotation,  but  no  substantial  difference  in  the 
mechanism  occurs.  The  shoulders  may  vary  greatly,  due  usually  to 
the  length  of  the  neck  and  the  time  when  they  are  compelled  to  follow 
the  head.  Thus,  they  may  enter  the  pelvis  directly  transversely  and 
rotate  indifferently  into  either  oblique  diameter,  and  at  any  level, 
which  will  also  control  the  movement  of  restitution. 

How  would  you  recognize  an  R.  O.  A.? 

Palpation  and  auscultation  will  give  the  same  results  as  in  an  L.  O;  A., 
except  that  all  will  be  found  on  the  right  side  of  the  mother's  abdomen. 

What  is  the  mechanism  of  delivery  in  the  R.  O.  A.  position? 

The  same  as  in  the  first,  or  L.  O.  A.  position,  except  that  the  sagittal 
suture  is  in  the  left  oblique  diameter,  and  the  occiput  directed  toward 
the  right  ilio -pectineal  eminence;  and  in  general  the  same  description 
will  apply  throughout,  substituting  right  for  left,  and  vice  versa. 

How  often  does  this  position  occur? 

Very  seldom,  owing  to  the  infrequency  of  left  lateral  obliquity  of 
the  womb,  and  the  presence  of  the  rectum  on  the  left  side  of  the  pelvis. 

How  is  the  head  situated  in  the  R.  O.  P.  position? 

The  occiput  is  opposite  the  right  sacro-iliac  symphysis,  the  fore- 
head opposite  the  left  ilio-pectineal  eminence,  and  the  sagittal  suture 
lies  in  the  right  oblique  diameter. 

What  are  the  causes  of  posterior  occipital  presentations? 

Normall}^  the  fetal  head  should  enter  the  pelvis  with  the  occiput 


128  COMPEND    OF    OBSTETRICS 

anterior  to  the  transverse  diameter  of  the  pelvic  inlet.     The  causes  of 
the  posterior  position  are: 

1.  Lack  of  relation  of  maternal  pelvis  and  fetal  head. 

2.  Lack  of  amniotic  liquid. 

3.  Weak  uterine  contractions. 

4.  Torn  or  relaxed  pelvic  floor. 

5.  Poor  flexion. 

How  may  the  head  enter  the  pelvis? 

1.  It  may  enter  with  the  occiput  anterior  to  the  transverse  diameter 
(right  or  left)  and  rotate  posteriorly. 

2.  It  may  enter  with  the  occiput  behind  the  transverse  line  and  rotate 
still  further  back  into  the  hollow  of  the  sacrum. 

What  is  the  mechanism  of  delivery  in  the  R.O.P.  position? 

There  are  four  different  processes  by  which  it  may  be  terminated. 

1.  Anterior  rotation  at  the  inlet. 

2.  Anterior  rotation  at  the  outlet,  or  during  descent. 

3.  Anterior  rotation  on  the  perineum,  and 

4.  Posterior  rotation  throughout. 

What  is  meant  by  anterior  rotation? 

The  rotation  of  the  head  so  as  to  bring  the  occiput  in  front,  thereby 
converting  the  position  into  an  R.  O.  A. 

How  does  anterior  rotation  occur? 

1.  From  the  fact  that  the  foramen  magnum  is  near  the  occipital  end  of 
the  head,  the  shoulders  are  thrown  further  back  in  this  position,  and 
therefore  the  right  shoulder  impinges  upon  the  vertebral  column  or 
promontory.  If  it  should  be  pushed  off  on  the  right  side,  the  child's 
back  will  be  brought  in  front.  This  twists  the  neck,  and  the  un- 
twisting force  of  its  elastic  structure  tends  to  rotate  the  head  with 
the  occiput  in  front.  This  occurs  most  easily  at  the  inlet,  next  at 
the  outlet  or  during  descent,  and  rarely,  even  when  the  head  has 
reached  the  perineum. 

2.  The  resistance  of  the  posterior  pelvic  wall  to  the  occiput  is  greater 
than  that  of  the  anterior  wall  upon  the  forehead,  owing  to  the  nar- 
rowing of  the  pelvis  under  the  sacro-iliac  arch,  which  also  aids  in 
anterior  rotation,  and,  according  to  some,  is  the  only  cause. 

What  must  occur  before  anterior  rotation? 

Flexion,  continued  until  the  circular  cervico-bregmatic  outline  is 
reached. 


THE    MECHANISM    OF    LABOR  1 29 

Under  what  circumstances  does  posterior  rotation  occur? 

If  the  child's  back  is  turned  toward  the  mother's  back  and  remains 
so,  the  head  cannot  rotate  anteriorly,  and  is  delivered  with  the  fore- 
head under  the  sub-pubic  arch.  Posterior  rotation  of  the  occiput  is 
favored  by  a  relaxed  or  torn  pelvic  floor,  lack  of  relation  between  the 
size  of  the  fetal  head  and  the  mother's  pelvis,  and  deficient  uterine 
contractions. 

What  difficulties  are  encountered  in  posterior  rotation? 

1.  The  labor  is  more  prolonged,  because  the  uterine  force  is  trans- 
mitted through  the  posterior  and  narrow  portion  of  the  pelvis. 

2.  The  perineum  is  endangered,  because  the  head  cannot  be  fully 
flexed  while  passing  over  it. 

How  may  we  recognize  the  R.  O.  P.  position  by  internal  examina- 
tion? 

1.  At  the  beginning  of  labor  the  anterior  fontanelle  (usually  large) 
will  be  found  very  accessible  in  front  and  to  the  left  in  right  occipito- 
posterior  position. 

2.  As  flexion  occurs  the  fontanelle  will  move  upward  and  become 
less  accessible,  which  is  directly  the  reverse  of  the  course  followed 
by  the  posterior  fontanelle  in  L.  O.  A. 

How  may  we  recognize  the  R.  O.  P.  by  external  examination? 

By  palpation  the  anterior  plane  of  the  fetus  can  be  felt  extending 
toward  the  front  of  the  mother.  The  fetal  members  can  be  more 
plainly  outlined  thus  than  when  the  back  is  directly  anterior.  The 
line  of  greatest  resistance  is  more  to  the  right  and  further  back  than 
in  an  R.  O.  A.  In  some  cases,  by  turning  the  mother  on  her  left  side, 
the  back  of  the  fetus  can  be  plainly  outlined. 

Auscultation  will  show  the  maximum  of  intensity  of  the  fetal 
heart-sounds  to  be  midway  on  a  line  extending  from  the  right  sacro- 
iliac joint  to  the  point  of  intersection  of  the  transverse  and  perpen- 
dicular lines. 

What  is  to  be  avoided? 

Attempts  to  rotate  the  head  without  reference  to  the  position  of 
the  shoulders.  It  endangers  the  child's  life,  from  over-twisting  of 
the  neck,  and  is  rarely  successful. 

How  is  the  diagnosis  L.  O.  P.  to  be  made  by  external  examination? 

The  same  as  in  R.  O.  P.,  except  that  the  fetus  lies  on  the  opposite 
side. 


130  COMPEND    OF    OBSTETRICS 

What  is  the  mechanism  of  delivery  in  the  L.  O.  P.  position? 

The  same  as  in  the  third  or  R.  O.  P.,  except  that  anterior  rotation 
converts  it  into  an  L.  O.  A.,  and  in  general  left  is  to  be  substituted 
for  right,  and  vice  versa,  throughout  the  description. 

How  should  posterior  rotations  of  the  occiput  be  managed? 

1.  In  many  cases  anterior  rotation  occurs  spontaneously. 

2.  As  soon  as  discovered  a  reasonable  effort  should  be  made  to  rotate 
the  shoulders  with  the  back  in  front  by  external  manipulation. 

If  this  fails,  the  vertex  may  be  rotated  anteriorly  by  inserting  a 
hand  in  the  uterus  and  grasping  the  head. 

4.  Have  the  patient  lie  on  the  same  side  that  the  back  of  the  child 
is  on;  this  causes  the  fundus  of  the  uterus  to  gravitate  downward 
and  favors  anterior  rotation. 

5.  If  pelvis  and  child  are  of  relative  size,  podalic  version  may  be 
performed. 

6.  If  some  anterior  rotation  has  been  gained  b}^  other  methods,  the 
Simpson  axis  traction  forceps  may  be  applied  and  traction  made 
in  the  axis  of  the  pelvic  inlet;  the  vertex  may  rotate  anteriorly. 

7.  If  direct  posterior  rotation  has  occurred,  apply  the  Tarnier  axis 
traction  forceps  and  deliver  in  flexion. 

What  are  the  causes  of  the  Face  presentation? 

1.  Hydramnios. 

2.  Deformities  or  contractions  of  the  pelvis. 

3.  Twin  pregnancies. 

4.  The  projecting  rim  of  a  placenta  praevia. 

5.  From  a  misdirection  of  the  uterine  axis  (due  to  pendulous  abdomen 
and  the  like)  the  contractions  may  propel  the  head,  originally  pre- 
senting the  vertex  in  such  manner  that  its  occiput  is  arrested  at  the 
brim,  while  the  facial  end,  being  free,  descends.  Thus  an  L.  O.  A 
may  be  converted  into  an  R.  M.  P.,  and  an  R.  O.  P.  into  an  L.  M.  A. 

6.  External  violence  or  jarring  may  disturb  and  change  the  presenta- 
tion. 

7.  Congenital  goiter,  spasmodic  contraction  of. the  neck  muscles  of 
the  fetus  thus  extending  the  head  may  be  a  cause,  or  the  child 
may,  by  reflex  movements,  extend  its  head.  It  occurs  about  once 
in  250  labors.  It  is  more  common  in  multigravidous  than  in 
primagravidous  patients. 

What  plane  and  diameters  are  described  in  the  Face  presentation? 

A  plane  drawn  through  the  anterior  limit  of  the  anterior  f  ontanelle. 


THE   MECHANISM    OF    LABOR  I3I 

the  malar  bones,  and  the  junction  of  the  chin  and  neck,  is  called  the 
trachelo-bregmatic  plane. 

It  is  of  elliptical  outline  and  nearly  parallel  to  the  cervico-breg- 
matic  plane,  but  smaller.  Its  long  diameter  is  called  the  trachelo- 
bregmatic;  its  transverse  diameter,  drawn  from  one  malar  bone  to 
the  opposite,  thg  bi-malar. 

How  is  the  head  situated  in  the  L.  M.  A.  position? 

The  chin  is  opposite  a  point  in  front  of  the  left  acetabulum;  the 
anterior  fontanelle  is  opposite  the  right  sacro-iliac  symphysis.  The 
features  of  the  face  (eyes,  nose,  mouth,  etc.)  may  be  felt  between 
the  points. 

How  could  an  L.  M.  A.  be  diagnosticated  before  birth? 

Palpation  will  show  the  fetal  lines  in  nearly  the  same  position 
as  in  an  R.  O,  P. 

Auscultation  will  show  the  maximum  of  intensity  of  the  fetal  heart- 
sounds  to  be  on  the  transverse  line  to  the  left  of  the  perpendicular  line. 

What  is  the  mechanism  of  delivery  in  the  L.  M.  A.  position? 

The  head  descends  in  complete  extension  with  its  trachelo-breg- 
matic diameter  presenting  in  the  right  oblique  diameter,  and  without 
difficulty,  until  the  cervico-bregmatic  plane  has  entered  the  pelvis. 
By  this  time  the  diameter  of  the  neck  or  upper  part  of  the  chest  is 
added  to  the  cervico-bregmatic  diameter,  and  as  this  constitutes  too 
large  a  bulk  to  pass,  one  of  two  things  now  occurs:  if  the  head  of  the 
fetus  and  the  mother's  pelvis  are  of  relative  size  and  the  chin  con- 
tinues its  anterior  rotation  until  it  is  under  the  pubic  arch,  it  is  easily 
born  in  flexion.  The  left  or  anterior  shoulder,  after  delivery  of  the 
head  rotates  under  the  symphysis  causing  the  face  to  turn  to  the 
mother's  left  side.  The  expulsion  of  the  body  follows.  If,  however, 
the  chin  rotates  posteriorly,  labor  ceases  and  impaction  occurs. 

How  is  this  difficulty  overcome? 

As  soon  as  the  head  can  reach  far  enough  to  be  acted  on  by  the 
perineum,  the  perineal  force  will  cause  the  head  to  be  flexed,  and  allow 
it  to  sweep  easily  over  the  perineum.  Therefore,  if  the  head  is  small, 
or  the  neck  long,  there  may  be  no  delay  in  flexion  and  delivery. 
Otherwise  the  head  must  remain  stationary  until  it  is  moulded  and 
wire-drawn,  so  as  to  enable  it  to  reach  the  perineum.    • 

What  effect  has  this  delay,  etc.,  upon  the  child? 

I.  It  is  endangered  by  the  pressure  upon  its  cervical  structure. 


132 


COMPEND    OF   OBSTETRICS 


2.  The  caput  succedaneum  forms  easily  upon  the  face,  and  the  parts 
may  be  perilously  swollen  and  infiltrated. 

What  treatment  is  demanded  and  why? 

Since  the  delivery  can  be  readily  accomplished  by  securing  flexion 
after  the  face  has  reached  the  inferior  strait,  we  should  assist  the 
mechanism — 

1.  By  attempting  to  flex  the  head  with  the  fingers,  and 

2.  With  the  forceps,  if  the  fingers  fail,  or  traction  is  necessary  to 
bring  the  head  low  enough  to  be  flexed. 

3.  When  the  head  has  reached  the  pelvic  floor,  the  chin  being  anterior, 
and  extension  complete,'  delivery  may  be  effected  by  axis-traction 
forceps  applied  to  the  sides  of  the  child's  head.  Delivery  is  accom- 
plished in  complete  flexion  over  the  perineum,  the  chin  being  under 
the  pubic  arch. 


Fig.  50. 


-Face  Presentation.     Delivery  of  the  Child's  Head  in  Complete 
Extension  by  Forceps. — {Edgar.) 


If  the  chin  remains  behind  and  the  head  cannot  be  flexed,  a 
podalic  version  may  be  performed  and  the  child  delivered  this  way. 

If  the  patient  is  in  a  hospital  and  has  not  been  handled  there  is 
no  reason  why  these  chin  posterior  cases  should  not  be  delivered 
by  Caesarean  section. 


THE    MECHANISM   OF    LABOR  I33 

How  can  an  R.  M.  A.  position  be  diagnosticated  before  birth? 

Palpation  will  show  the  fetal  lines  to  be  in  nearly  the  same  position 
as  in  an  L.  O.  P. 

The  maximum  of  intensity  of  the  fetal  heart-sounds  will  be  on 
the  transverse  line  to  the  right  of  the  perpendicular  line. 

What  is  the  mechanism  of  the  R.  M.  A.  position? 

The  face  enters  the  pelvis  with  the  chin  in  front  and  to  the  right, 
and  in  general  the  same  description  will  apply,  substituting  right 
for  left,  and  vice  versa,  throughout. 

How  can  an  R.  M.  P.  be  diagnosticated  by  external  methods? 

Palpation  will  show  the  fetal  back  to  be  anterior  and  toward  the 
left  side  of  the  mother's  abdomen.  The  examining  hand  sinks  more 
deeply  into  the  right  side  of  the  pelvic  cavity  than  in  the  left. 

Auscultation  will  show  the  maximum  of  intensity  of  the  fetal 
heart  to  be  on  the  transverse  line  and  to  the  left  of  the  perpen- 
dicular. 

What  is  the  mechanism  of  the  R.  M.  P.  position? 

1.  The  trachelo-bregmatic  plane  enters  the  pelvis  with  the  chin 
opposite  the  right  sacro-iliac  symphysis.  The  forehead  remains 
stationary  at  the  front  part  of  the  brim,  while  the  base  of  the 
skull  and  upper  part  of  the  chest  attempt  to  advance  under  the 
sacro-iliac  arch,  which  is  impracticable. 

2.  The  shoulders  will  thus  be  made  to  impinge  upon  the  vertebral 
column,  and  will  have  a  tendency  to  be  pushed  to  the  right  of 
the  promontory,  with  the  back  in  front.  This  will  twist  the  neck, 
and  tend  to  rotate  the  head  into  an  R.  M.  A.  position,  and  the 
labor  is  terminated  as  in  that  position. 

The  key  to  the  mechanism,  therefore,  is  anterior  rotation  of  the 
chin  from  the  right  sacro-iliac  joint  forward  to  the  left  until  it  is  under 
the  pubic  arch  as  labor  advances  and  engagement  occurs.  If  this  fails 
to  occur,  the  head  and  chest  become  tightly  wedged,  and  unless  the 
head  is  very  small,  or  the  pelvis  large,  delivery  is  impossible. 

What  is  the  mechanism  of  the  L.  P.  M.  position? 

The  face  enters  the  pelvis  with  the  chin  behind  and  to  the  left,  and 
in  general  the  same  description  will  apply,  substituting  left  for  right, 
and  vice  versa,  throughout.  External  diagnosis  is  made  in  the  same 
manner  as  in  R.  M.  P.,  except  that  the  fetal  lines  are  felt  and  heart- 
sounds  heard  on  the  opposite  side. 


134  COMPEND    OF    OBSTETRICS 

What  is  the  Brow  presentation? 

A  variety  of  the  Face  presentation,  the  upper  part  of  the  face 
presenting.  It  is  converted  either  into  a  full  face  or  into  a  vertex 
presentation,  or  cannot  be  delivered  naturall}^  unless  the  head  is 
very    small. 

What  plane  and  diameter  are  described  in  the  Breech  presentation? 

A  plane  drawn  transversely  through  the  ilia  and  sacrum,  called 
the  bis-iliac,  from  its  long  diameter,  drawn  between  the  crests  of  the 
ilia.  It  is  of  elliptical  outline  and  almost  identical  with  that  of 
the  shoulders. 

How  can  an  L.  S.  A.  be  diagnosticated  before  labor? 

Palpation  wiU  show  the  rounded  breech,  larger  than  the  head 
and  without  a  constricted  part  above  it,  to  be  in  the  left  lower  seg- 
ment of  the  uterus.  The  fetal  back  is  anterior  and  toward  the  left 
side  of  the  mother's  abdomen. 

Auscultation  shows  the  maximum  of  intensity  of  the  fetal  heart- 
sounds  to  be  at  a  point  near  the  perpendicular  line,  on  a  line  extending 
from  the  middle  of  the  last  false  rib  to  the  intersection  of  the  trans- 
verse and  perpendicular  lines.  Digital  examination  by  vagina  wih 
reveal  the  buttocks  and  genital  organs  either  at  the  pelvic  brim 
before  engagement  or  within  the  pelvic  brim  after  engagement  has 
occurred.     The  fetal  back  is  toward  the  mother's  left  side. 

How  is  the  breech  situated  in  the  L.  S.  A.  position? 

The  sacrum  is  in  front  of  the  left  acetabulum,  the  right  ilium 
under  the  left  sacro-iliac  symphysis;  the  left  ilium  in  front  of  the  right 
acetabulum,  and  the  pubes  in  the  free  space  in  front  of  the  right 
sacro-iliac  symphysis;  the  bis- trochanteric  diarneter  of  the  fetus  is  in  re- 
lation with  the  left  diagonal  of  the  mother's  pelvis. 

What  is  the  mechanism  of  the  L.  S.  A.  position? 

The  bis-iliac  or  bis-trochanteric  diameter  enters  the  pelvis  in  the  left 
oblique  diameter,  the  fetal  sacrum  being  in  relation  with  the  mother's 
left  ilio-pectineal  eminence.  Rotation  occurs  during  descent,  from 
right  to  left,  so  that  when  it  arrives  at  the  vulva,  the  left  ilium  is  directly 
in  front  and  the  sacrum  directly  toward  the  left  side.  Since  the  breech 
is  quite  compressible,  advantage  is  taken  of  this  to  enable  it  to  pass 
out  of  the  vulva  with  less  distention  of  the  perineum,  by  one  of  the  hips 
passing  in  advance  of  the  other,  the  left  hip  is  at  the  pubic  joint  and 
the  right  sweeps  over  the  perineum.     The  breech  being  born,  the  body 


THE    MECHANISM    OF    LABOR  135 

and  legs  emerge,  next  the  shoulders,  following  the  same  mechan- 
ism, an'd  finally  the  head,  which  enters  in  the  right  oblique  diame- 
ter rotates  from  left  to  right,  and  passes  down  strongly  flexed. 

What  is  the  mechanism  of  the  R.  S.  A.  position? 

The  same  as  in  the  first,  substituting  right  for  left,  etc.  The 
diagnosis  previous  to  labor  is  to  be  made  on  the  same  principle. 

What  is  the  mechanism  of  the  R.  S.  P.  and  L.  S.  P.  positions? 

So  far  as  the  breech  is  concerned  the  mechanism  is  the  same  as 
in  the  sacro-anterior  position  (making  allowance  for  change  in 
direction).  But  when  the  head  enters  the  pelvis  it  will  be  in  an 
occipito-posterior  position,  and  there  will  be  the  same  need  for 
anterior  rotation  as  in  the  corresponding  vertex  positions. 

How  is  the  diagnosis  of  these  to  be  made  by  palpation  and  ausculta- 
tion? 

In  the  R.  S.  P.  the  anterior  plane  of  the  fetus  is  toward  the  mother's 
front,  the  back  being  toward  the  right  sacro-iliac  joint.  The  maxi- 
mum of  intensity  of  the  fetal  heart-sounds  is  on  the  same  side  as  in  an 
R.  S.  A.,  but  at  a  point  farther  from  the  perpendicular  line.  In  an 
L.  S.  P.  the  diagnosis  is  made  on  the  same  principle,  substituting,  of 
course,  left  for  right. 

What  dangers  are  connected  with  the  breech  presentation? 

1.  Compression  of  the  funis,  4.  Extension  of  arms  over  head. 

2.  Premature  respiration.  5.  Extension  of  the  head. 

3.  Inhalation  of  mucus,  etc.  6.  Rupture  of  the  perineum. 

How  may  the  funis  be  compressed? 

If  there  is  any  delay  in  the  birth  of  the  head  after  the  body  is  born, 
the  funis  may  be  compressed  between  the  head  and  pelvic  walls,  thus 
asphyxiating  the  child. 

What  is  premature  respiration? 

After  the  birth  of  the  body,  the  contact  of  air  may  excite  respiration 
and  abolish  the  placental  circulation.  Delay  after  this  may  result  in 
asphyxia.  Pressure  on  the  cord  while  the  child  is  still  within  the  uterus 
or  even  if  the  body  is  born  and  the  head  is  within  the  pelvis  will  produce 
attempts  at  respiration  causing  the  child  to  swallow  amniotic  liquid 
and  mucus  resulting  in  fatal  asphyxia,  or  on  the  other  hand  the  child 
may  not  be  able  to  get  enough  air  to  support  life. 


136  COMPEND    OF    OBSTETRICS 

How  may  inhalation  of  mucus  occur? 

The  child  may  respire  while  the  head  is  detained  in  the  passages, 
and  may  draw  mucus  or  fluids  into  the  lungs,  causing  either  asphyxia 
or  pneumonia  after  birth. 

How  may  the  arms  be   extended? 

The  arms  are  naturally  flexed  upon  the  child's  body,  and  pass  out 
with  it,  but  if  arrested  by  the  pelvic  walls,  they  may  be  extended  along- 
side of  the  head,  increasing  its  diameter,  and  making  delivery  impos- 
sible until  they  are  brought  down. 

How  are  the  arms  to  be  brought  down? 

One  or  two  fingers  are  to  be  passed  by  the  child's  head  and  laid  upon 
an  arm  from  behind.  The  arm  is  then  to  be  pushed  across  the  child's 
face,  and  so  on  until  brought  down  by  the  side  of  the  body.  This  may 
be  repeated  with  the  other,  if  both  are  extended. 

How  may  the  head  be  extended? 

The  head  is  usually  so  tightly  grasped  by  the  uterus  and  vaginal 
walls  as  to  be  kept  flexed,  but  if  the  pelvis  is  small,  or  improper  trac- 
tion is  made  upon  the  body,  it  may  be  extended,  and  will  then  present  a 
large  outline  in  passing  through  the  pelvis.  This  makes  its  advance 
more  diffcult,  and  may  cause  a  laceration  of  the  perineum. 

What  is  the  fetal  mortality  in  the  breech  presentation? 

From  30  to  50  per  cent. 

How  should  a  breech  case  be  managed  throughout? 

As  a  rule,  labor  should  not  be  interfered  with  until  the  breech  is 
born.  The  patient's  strength  should  be  kept  up  and  she  had  better 
be  in  bed,  preferably  lying  on  the  side  toward  which  the  child's  back 
points.  Always  preserve  the  membranes  as  long  as  possible.  The 
first  stage  of  a  breech  presentation  is  always  long,  as  t;he  breech 
makes  a  much  poorer  dilator  than  does  the  head.  The  physician 
should  then — 

I .  As  soon  as  the  hips  are  delivered,  draw  down  a  loop  of  the  cord,  as 
otherwise  it  may  be  compressed  between  the  child's  head  and  the 
pelvic  brim  during  the  descent  of  the  former,  and,  not  being  able  to 
pass  down  as  rapidly  as  is  required,  it  may  be  torn  off  at  the  umbili- 
cus or  so  stretched  as  to  interfere  with  the  placental  circulation.  If 
the  cord  is  pulsating  strongly,  place  the  loop  thus  drawn  down  out 
of  the  way  in  the  postero-lateral  part  of  the  pelvic  excavation.     If 


THE    MECHANISM    OP    LABOR  I37 

the  pulsation  is  feeble  or  absent,  hurry  the  delivery.  As  soon  as  the 
body  is  born  as  far  as  the  shoulders,  it  should  be  wrapped  in  a  warm 
wet  towel  to  prevent  premature  attempts  at  respiration  and  the 
consequent  inspiration  of  mucus  from  the  vagina. 


/■ 


\       \ 


Fig.  si. — Breech  Extraction.     Traction  on  the  Anterior    Leg  and  Groin 
AND  Posterior  Groin.— (Edgar.) 


\ 


Fig.  52. — Breech  Extractioii.     Traction  on  Both  Groins. —  (Edgar.) 

2.'  In  many  cases  the  shoulders  effect  spontaneous  engagement. 
When,  however,  this  is  shown  the  child's  body  wrapped  in  a  warm 
towel  should  be  grasped  in  one  hand  while  the  other  makes  pressure 
over  the  pubic  region.     The  child's  body  should  be  carried  slightly 


138 


COMPEND    OF    OBSTETRICS 


upward  and  to  the  opposite  side  from  that  on  which  the  back  is. 
The  object  of  this  is  to  bring  the  posterior  shoulder  into  the  inlet 
and  at  the  same  time  not  to  disturb  flexion  .of  the  head. 


Fig.  53. — Breech  Extraction.      Downward  Traction  on  the  Groins. — {Edgar.) 


f\ 


^y^- 


FiG.  54. — Extraction  of  the  APTER-coinNG  Head.     Delivery  of  the  Posterior 

Arm. — {Edgar.) 

3.  As  soon  as  the  body  is  born,  bring  down  the  arms,  if  extended. 

4.  If  the  head  is  not  at  once  born,  pass  two  fingers  to  its  mouth,  to 


THE    MECHANISM    OF   LABOR  139 

maintain  the  head  in  flexion  and  to  secure  a  supply  of  air  and  to 
admit  of  respiration. 
5.  Draw  the  body  down  against  and  parallel  to  the  perineum  (to  flex 
the  head).  Then  elevate  the  body,  turning  it  over  on  the  mother's 
abdomen  while  making  traction.  An  assistant,  if  possible,  should 
press  upon  the  Jiypogastrium,  to  force  the  head  down.  Repeat  the 
manoeuver,  if  necessary. 

What  is  Smellie's  method  of  extraction  of  the  after-coming  head? 

In  this  method  the  body  of  the  child  is  wrapped  in  a  warm  napkin 
and  placed  astride  the  operator's  arm.  The  index  and  middle  fingers 
are  on  the  canine  fossa  on  each  side  of  the  child's  nose.  Upward 
pressure  is  made  at  the  same  time  with  the  fingers  of  the  other  hand 
upon  the  occiput.  By  raising  the  trunk,  the  head  is  rolled  out  over  the 
perineum.  The  head  must  be  completely  rotated  before  this  method 
can  be  used.  This  method  is  particularly  adapted  for  extraction  when 
the  fetal  head  has  entered  the  pelvis. 

What  is  the  so-called  Smellie-Veit  modified  method? 

This  consists  in  combined  traction  on  the  chin  and  shoiilders,  and 
is  frequently  used  when  the  above  method  has  failed.  One  hand  is 
introduced  as  in  the  Smellie  method,  and  the  index  and  middle  fingers 
of  the  other  hand  should  be  forked  upon  the  shoulders.  A  somewhat 
downward  traction  should  be  made,  until  the  cervical  region  is  under 
the  pubes.  If  by  an  upward  movement  of  both  arms  the  body  is 
elevated,  the  face  will  rotate  over  the  perineum.  It  is  claimed  that  by 
this  method  the  greatest  traction  can  be  used  with  the  least  damage  to 
the  child. 

What  means  should  be  used  where  the  occiput  has  rotated  into  the 
hollow  of  the  sacrum? 

Lusk  advises  in  cases  where  the  forehead  is  pressed  against  the  sym- 
physis to  reverse  the  above-named  method.  As  the  fingers  are 
forked  upon  the  shoulders,  the  back  of  the  child  should  rest  upon  the 
arm.  The  chin  should  be  flexed  with  one  or  two  fingers  of  the  other 
hand.     Traction  should  be  made  in  a  downward  direction. 

What  is  the  method  of  Prague? 

The  feet  are  seized  with  one  hand,    and  the  body  directed  nearly 
vertically  downward.     While  this  is  being  done  the  fingers  of  the  other 
hand  are  hooked  upon  the  shoulders,  so  that  the  finger-tips  rest  above 
10 


140 


COMPET"^   OF   OBSTETRICS 


each  clavicle.  Both  hands  exercise  traction  at  the  same  time.  It  is 
sometimes  necessary,  when  uterine  contractions  are  weak,  to  have  an 
assistant  make  pressure  on  the  head  through  the  abdominal  walls. 
After  the  head  has  passed  the  superior  strait,  the  feet  should  be  quickly- 
raised  toward  the  mother's  abdomen. 


-j^S^/'  /  iLfrt^^"/''""'"^"  "'"W 


Fig.  55. — Method  of  Prague. 


How  should  this  method  be  modified  where  the  occiput  rotates  into 
the  hollow  of  the  sacrum? 

The  body  of  the  child  should  be  directed  toward  the  mother's 
abdomen,  so  as  to  cause  rotation  of  the  occiput  over  the  perineum. 

In  what  cases  is  the  Prague  method  of  greatest  service? 

In  somewhat  contracted  pelves,  in  which  the  chin  normally  is  par- 
tially extended  as  the  head  engages  in  the  sagittal  diameter  of  the 
brain.     (Lusk.) 


THE   MECHANISM    OF    LABOR  I4I 

What  caution  is  necessary  in  pulling  upon  the  child's  body? 

The  neck  breaks  with  the  weight  of  100  lb.,  and  decapitation 
occurs  with  120  lb.     (Matthews  Duncan.) 

Under  what  circumstances  is  earlier  interference  indicated? 

When  the  labor  is  unduly  protracted  we  may  suspect  that  the  soft 
breech  is  spreading  out  and  being  wedged  in  the  pelvis,  rather  than 
being  molded  into  a  shape  suitable  for  passing.     We  may  then — 


Fig.  s6. — Left  Dorso- anterior  Position  and  Presentation. 

1.  Carefully  introduce  the  hand  and  bring  down  one  or  both  legs  to 
use  in  making  traction,  or 

2.  We  may  use  a  fillet.  Pass  a  silk  handkerchief  or  roller  bandage 
over  the  child's  groin,  to  use  in  making  traction,  A  "blunt  hook" 
or  other  metallic  instrument  should  never  be  used  on  a  living  child. 

What  varieties  of  the  breech  presentation  occur? 

One  or  both  feet  or  legs  may  come  in  advance  of  the  breech,  which 
is  called  a  "breech  footling." 

How  does  the  descent  of  one  or  both  feet  affect  the  mechanism? 

Very  little,  except  by  offering  a  temptation  to  pull  upon  them,  and 
thus  to  extend  the  arms  and  head.  The  first  stage  of  labor  may  be 
longer,  from  the  want  of  an  even  dilating  wedge  in  the  os. 


142  COMPEND    OF    OBSTETRICS 

How  is  the  child  situated  in  the  L.  D.  A.  position? 

The  right  shoulder  presents  in  the  os  uteri,  the  head  lying  in  the 
left  iliac  fossa  and  the  breech  in  right  iliac  fossa,  or  a  little  higher. 

How  is  the  child  situated  in  the  R.  D.  A.  position? 

The  left  shoulder  presents  in  the  os,  the  head  lying  in  the  right 
iliac  fossa,  and  the  breech  in  the  left  iliac  fossa,  or  a  little  higher. 

How  can  we  diagnosticate  these  two  positions  previous  to  labor? 

The  long  axis  of  the  fetus  will,  by  palpation,  be  found  in  both  posi- 
tions to  extend  transversely  across  the  pelvis.  The  hard  globe  of  the 
head  will  be  found  in  the  right  iliac  fossa,  in  the  R.  D.  A.  position, 
while  the  broader  breech  will  be  found  higher  up  on  the  opposite  side. 
In  the  L.  D.  A.  the  opposite  position  of  head  and  breech  obtains. 

Auscultation  will  give  the  heart-sounds  on  the  perpendicular  line 
midway  between  its  point  of  intersection  with  the  transverse  line 
and  the  pubes.  The  point  of  maximum  intensity  is  nearly  the  same 
for  all  transverse  positions. 

How  is  the  child  situated  in  the  R.  D.  P.  position? 

The  right  shoulder  presents  in  the  os,  the  head  lying  in  the  right 
iliac  fossa,  and  the  breech  in  the  left  iliac  fossa,  or  a  little  higher. 

How  is  the  child  situated  in  the  L.  D.  P.  position? 

The  left  shoulder  presents  in  the  os,  the  head  lying  in  the  left  iliac 
fossa,  and  the  breech  in  the  right  iliac  fossa,  or  a  little  higher.  The 
main  points  of  differentiation  by  external  examination  are  the  same  in 
R.  D.  P.  and  L.  D.  P.  as  in  the  L.  D.  A.  and  R.  D.  A.,  except  that  the 

head  and  breech  can  be  outlined  on  opposite  sides  of  the  pelvis. 

What  are  the  modes  of  delivery  in  the  transverse  presentation? 

There  is  no  natural  mechanism,  but 

1.  The  child,  if  very  small,  may  be  doubled  up  and  expelled.     (Rare.) 

2.  The  child  may  be  spontaneously  turned  in  utero,  so  that  it  becomes 
either  a  vertex  or  breech  presentation.     (Rarer.) 

3.  After  the  child  has  been  doubled  up,  the  breech  may  be  pushed 
down  after  great  efforts.  This  is  called  spontaneous  evolution. 
(Rarest.) 

How  should  a  transverse  presentation  be  managed? 

We  should  not  await  any  of  the  spontaneous  methods,  but  turn 
the   child  to   a  vertex   of  breech  presentation.     (See   Version.)     If 


PATHOLOGY   OF    LABOR  1 43 

this  is  impossible,  we  will  have  to  perforate  the  chest  and  reduce  the 
size  of  the  child.  (See  Embryotomy.)  If  the  child  is  living  and 
the  mother  is  in  good  condition  and  not  infected  and,  especially  if 
hospital  facilities  are  at  hand,  the  child  may  be  delivered  by  abdom- 
inal Caesarean  section. 

What  variety  of  the  transverse  presentation  occurs? 

The  hand  or  arm  may  be  in  advance  of  the  shoulder,  and  may 
present  at  the  vulva.  Care  should  be  taken  not  to  confound  the 
hand  and  foot  with  each  other. 

What  anomalous  presentations  are  occasionally  observed? 

I.  The  body  of  the  child  may  be  so  doubled  that  the  feet  present 
with  the  vertex  or  face.  2.  One  or  both  hands  may  be  added  to  the 
vertex  or  face  presentation.  3.  The  funis  may  present  with  any  of 
the  others. 

PATHOLOGY  OF  LABOR 

DYSTOCIA 

What  is  dystocia? 

The  technical  name  for  labor  which  departs  from  the  normal  stand- 
ard. 

How  is  labor  rendered  abnormal? 

By  disease,  defect,  or  accident  affecting — 
I.  The  motive  force.     2.  The  fetus   and   its   attachments.     3.  The 
mother's  tissues  or  general   condition.     We  have,  therefore,  three 
classes    of    dystocia:  i.  Uterine.     2.  Fetal.     3.  Maternal. 

In  what  way  may  the  motive  force  be  affected? 

It  may  be:"  i.  Excessive.     2.  Deficient.     3.  Irregular. 

What  evils  may  excessive  uterine  action  occasion? 

1.  Precipitate  labor,  involving  a  too  sudden  emptying  of  the  womb, 
with  laceration  of  the  cervix  and  perineum. 

2.  Rupture  of  the  womb  when  there  is  much  resistance. 

What  is  deficient  action? 

Uterine  inertia,  or  any  deficiency  in  the  power,  length  or  frequency 
of  the  uterine  contractions. 

What  evils  may  uterine  inertia  occasion? 

The  principal  one,  and  which  involves  many  evils,  is  delay  in  the 


144  COMPEND    OF    OBSTETRICS 

labor.     Delay  is  hurtful,  more  or  less,  according  to  the  stage  in  which 
it  occurs. 

1.  At  all  times  the  protraction  of  labor  beyond  its  normal  limits 
enfeebles  the  mother  and  endangers  the  child's  circulation. 

2.  In  the  second  stage  additional  dangers  arise,  from  pressure  upon 
the  maternal  tissues,  with  possibilities  of  sloughing,  fistulas,  and 
septic  processes. 

3.  In  the  third  stage  inertia  may  lead  to  fatal  hemorrhage,  throm- 
bosis in  uterine  sinuses,  with  subsequent  septicemia  and  other 
diseases. 

What  are  the  causes  of  uterine  inertia? 

1.  Defective  innervation  or  circulation  of  the  uterus. 

2.  Paralysis  of  the  uterus  from  over-distention. 

3.  Organic  defects  in  the  uterine  muscles. 

In  what  ways  may  the  innervation  and  circulation  of  the  womb 
be  affected? 

The  nervous  supply  of  the  uterus  being  spinal,  cerebral  (vaso- 
motor), and  ganglionic,  it  may  be  affected  by  mental  emotion,  the 
shrinking  from  pain  of  the  hysterical  temperament,  improper  ven- 
tilation, or  from  either  direct  or  indirect  disturbance  of  the  uterine 
center.  The  latter  may  be  occasioned  by  malarial  poisoning  or  by 
reflex  influences  from  other  disturbed  organs.  Premature  rupture  of 
the  membranes  is  frequently  associated  with  inertia,  probably  as  cause. 

How  may  the  uterus  be  paralyzed  from  over-distention? 

The  walls  of  the  uterus  may  be  mechanically  over- distended  by 
twins  or  dropsy  of  the  amnion,  making  the  contractions  feeble. 

What  organic  defects  are  met  with? 

The  uterus  which  has  frequently  gone  through  the  processses  of 
pregnancy  often  has  its  fibrous  and  uncontractile  elements  increased 
at  the  expense  of  the  muscular  tissue.  This  decreases  the  power  of  the 
uterus;  hence,  old  multiparas  frequently  have  protracted  labors  from 
this  cause.     It  is  said  that  fatty  degeneration  sometimes  occurs. 

How  should  uterine  inertia  be  treated? 

If  sufficiently  great  to  unduly  prolong  labor,  we  should — 

1.  Endeavor  to  ascertain  and  remove  the  cause. 

2.  Place  the  woman  under  the  best  hygienic  conditions. 

3.  If  the  source  of  reflex  disturbances  cannot  be  removed,  we  may 


PATHOLOGY   OF    LABOR  I45 

quiet  the  nerve  center  by  chloral,  opium,  or  the  bromid  of  potassium, 

after-  which  the  inertia  is  commonly  relieved. 

4.  When  the  patient  is  suffering  from  fatigue  during  a  protracted 
labor,  quinin  and  tonic  doses  of  strychnin  are  of  great  use. 

5.  Massage  and  stroking  of  the  uterus  through  the  abdominal  walls 
may  be  tried. 

6.  If  over-distension  exists,  we  should  early  rupture  the  membranes. 

7.  In  the  second  stage  we  may  supplement  the  uterine  force  (a)  by 
the  Walcher  position,  Kristeller's  method;  (&)  by  the  use  of  hypo- 
dermatic injection  of  "pituitrin; "  (c)  by  the  forceps. 

What  is  the  Walcher  position? 

The  patient  being  in  the  dorsal  position,  is  brought  to  the  edge  of  a 
bed  or  table  of  sufficient  height  that  her  thighs  are  allowed  to  hang 
down  so  that  the  toes  just  touch  the  floor,  or  her  feet  may  be  supported 
on  the  lower  rung  of  a  chair.  The  buttocks  must  be  slightly  over  the 
edge  of  the  bed.  The  result  of  this  position  is  to  tilt  the  pelvis  down- 
ward and  backward,  at  the  same  time  stretching  the  pubic  joint.  The 
result  of  this  is  to  slightly  enlarge  the  pelvic  brim.  This  position  may 
be  supplemented  by  Kristeller's  method. 

What  is  Ejristeller's  method? 

Place  the  hands  on  the  abdomen  (facing  the  woman's  feet).  En- 
deavor at  intervals  to  push  the  child  through  the  pelvis.  Called  also 
expression. 

What  should  be  avoided  in  treating  inertia? 

The  use  of  oxytocics. 

What  are  oxytocics? 

Drugs  credited  with  the  power  of  directly  affecting  the  uterine 
muscle,  and  of  causing  or  strengthening  contractions.  As  examples 
of  this  class  of  agents  we  have  ergot,  cinnamon,  borax,  and  many  others. 
Of  these  the  one  most  used  is  ergot. 

What  objections  exists  to  the  use  of  ergot  in  labor? 

It  is  uncertain  in  action,  when  it  does  act,  causes  tonic  contrac- 
tion of  the  uterus  and  an  unremitting  effort  to  expel  the  child.  If 
this  takes  place  before  the  os  is  dilated,  laceration  of  the  cervix  may 
occur;  if  the  head  is  large,  rupture  of  the  womb  may  take  place;  in 
any  event,  the  placental  circulation  will  be  continuously  compressed, 
and  the  child  in  danger  of  asphyxia.     Ergot  should  never  be  given 


146  COMPEND   OF   OBSTETRICS 

before  the  birth  of  the  child,  and,  from  its  uncertainty,  should  never 
be  depended  upon  in  the  third  stage. 

What  objection  exists  to  the  use  of  stimulants? 

A  dose  of  whisky  is  often  given,  increasing  the  woman's  courage 
and  the  contractions  of  the  abdominal  muscles.  But  if  labor  is  not 
speedily  terminated,  reaction  follows,  and  the  labor  will  be  retarded. 

What  is  irregular  action  of  the  uterine  force? 

Irregular  contraction  of  special  fibers  instead  of  general  contrac- 
tion of  all.  Its  typical  form  is  called  "ante-partum  hour-glass  con- 
traction." In  this  condition,  a  circular  band  of  fibers,  usually  a  little 
above  the  cervix,  contracts  firmly  and  tonically,  while  the  rest  of  the 
womb  remains  inert.  This  holds  the  child  tightly  in  the  womb,  and 
suspends  normal  contractions. 

How  should  this  be  treated? 

Relaxation  should  be  attempted  by  anesthesia  or  by  emetic  doses 
of  ipecac.  These  failing,  our  only  resource  is  in  artificial  dehvery  by 
forceps,  or  Caesarean  section,  or  embryotomy. 

What  obstructions  to  delivery  are  encountered  in  the  maternal 
tissues? 

1.  At  the  OS  uteri:  rigidity,  edema,  atresia,  or  displacement. 

2.  In  the  vagina:  fibrous  bands,  atresia,  persistent  hymen. 

3.  An  unyielding  perineum. 

4.  Tumors,  including  a  distended  bladder  or  rectum. 

5.  External:  edema  and  thrombus  of  the  labia;  hernia. 

6.  Deformities  of  the  pelvis. 

What  is  rigidity  of  the  os  (or  cervix)  uteri? 

An  unyielding  and  undilatable  condition,  due — 

1.  To  organic  changes,  and 

2.  To  temporary  spasmodic  contraction  of  the  oral  fibers.  The  first 
form  is  due  to  inflammatory  or  hypertrophic  conditions,  by  which 
the  cervical  fibers  have  become  thickened  and  fibrous.  The  second 
form  may  occur  at  any  time  during  the  first  stage  of  labor,  and  is 
usually  associated  with  uterine  inertia. 

How  may  organic  and  functional  rigidity  be  distinguished? 

1 .  In  organic  rigidity,  the  edges  of  the  os  are  thick  and  de?ise,  and  the 
cervix  has  not  entirely  disappeared. 

2.  In  rigidity  from  spasm  the  edges  of  the  os  are  thin  and  tensBf  giving 


PATHOLOGY   OF   LABOR  1 47 

the  sensation  of  sharp,  wiry  resistance.  It  is  also  associated  with 
some  constitutional  disturbance,  the  woman  being  nervous  and 
restless  and  the  vagina  hot  and  less  moist  than  usual. 

What  treatment  is  indicated? 

1.  In  organic  rigidity,  the  uterine  contractions  should  be  allowed 
ample  time  to  Jorce  open  the  os;  this  failing,  incisions  should  be 
made  with  a  bistoury.  The  patient  should  be  placed  in  Sims' 
position,  the  speculum  introduced,  and  the  incisions  made  radiating 
from  the  os,  to  a  sufficient  extent  to  allow  the  head  to  come  through 
with  or  without  the  forceps.  The  condition  is  rare,  and  such 
extreme  measures  are  seldom  called  for. 

2.  Functional  rigidity  depends  upon  much  the  same  causes  as  uterine 
inertia,  and  demands  similar  hygienic  treatment..  Chloral,  gr. 
XV,  every  hour,  will  be  found  effective.  Over- stretching  may  be 
used.  This  is  accomplished  by  inserting  the  index  and  middle 
fingers  within  the  os,  and  spreading  them  forcibly,  so  as  to  stretch  the 
oral  fibers.  The  fingers  exert  so  little  real  force  that  no  judicious 
person  can  do  harni  with  this  procedure.  It  may  be  repeated  in  an 
hour,  or  with  two  or  three  successive  contractions.  If  necessary, 
Molesworth's  or  Barnes'  dilators  may  be  used,  to  dilate  with  more 
force  and  rapidity. 

What  is  edema  of  the  cervix? 

An  infiltration  of  serum,  especially  into  the  anterior  lip  of  the  cervix, 
which  impairs  its  dilatability.  It  is  due  to  pressure  from  the  child's 
head. 

What  is  the  indication  for  treatment? 

To  remove  the  cause;  as  long  as  the  head  remains  the  swelling  will 
continue;  hence,  deliver  with  forceps  before  it  becomes  too  extensive. 

What  is  atresia  of  the  os  uteri? 

Entire  closure  of  the  os,  due  to  inflammatory  adhesions  of  the  cer- 
vical lips.  It  is  very  rare,  and  demands  similar  treatment  to  organic 
rigidity. 

What  is  displacement  of  the  os  uteri? 

Removal  of  the  os  from  its  normal  place  in  the  vagina,  usually  due 
to  a  forward  displacement  of  the  fundus.  This  in  turn  is  due  to  a 
relaxed  condition  of  the  abdominal  muscles.  [Cases  are  recorded  in 
which  the  fundus  of  the  womb  rested  on  the  woman's  knees,  in  the  sit- 


148  COMPEND    OF   OBSTETRICS 

ting  posture,  throwing  the  os  so  far  back  as  to  make  it  inaccessible.] 
The  same  condition  is  sometimes  caused  by  tumors  displacing  the 
womb  in  any  direction,  but  the  usual  displacement  of  the  os  is  back- 
ward, toward  the  promontory. 

What  are  the  dangers  of  this  condition? 

1.  The  child's  head  is  pressed  against  the  anterior  wall  of  the  cervix 
and  is  unable  to  leave  the  womb  unless  through  a  rent  in  the  anterior 
wall. 

2,  The  incautious  examiner  may  mistake  the  thinned  wall  for  the 
membranes,  and  make  the  rent  himself.  This  condition  is  common 
enough  to  warrant  every  one  in  making  the  discovery  of  the  os  and 
the  condition  of  its  edges  the  first  duty  in  labor. 

What  treatment  is  indicated? 

Replace  the  womb  by  pushing  the  fundus  backward,  while,  if  pos- 
sible, the  finger  is  hooked  into  the  os  and  it  is  pulled  forward.  If 
the  displacement  has  been  great,  a  bandage  should  be  applied  around 
the  abdomen  to  retain  the  uterus  in  position. 

What  treatment  is  indicated  for  a  small  vagina,  obstructive  bands, 
etc.? 

A  vagina  small  enough  to  impede  delivery  will  require  the  for- 
ceps to  be  used.  Bands  or  a  persistent  hymen  may  be  incised.  While 
the  head  distends  and  makes  tense  the  band,  a  knife  placed  between  the 
head  and  band  is  allowed  to  be  pushed  through.  Care  should  be  taken 
to  cut  as  little  as  possible,  and  to  tear  rather  than  cut  after  the  edge  is 
severed. 

How  may  the  perineum  obstruct  labor? 

1 .  The  perineum  may  be  congenitally  defective  in  structure,  or  have 
been  imperfectly  developed^duringpregnancy,  constituting  organic 
rigidity. 

2.  Or  its  muscular  fibers  may  be  in  a  condition  of  spasm  or  functional 
rigidity.  The  same  measures  may  be  used  which  are  applicable  in 
rigidity  of  the  cervdx,  but  the  forceps  may  be  used  instead,  which 
render  us  independent  of  the  perineum. 

What  is  to  be  done  when  tumors  obstruct  delivery? 

The  treatment  of  a  distended  bladder  and  rectum  is  obivous. 
Empty  them.  No  rule  can  be  laid  down  for  other  tumors.  If  the 
tumor  is  safely  removable  or  can  be  diminished  in  size,  it  may  be  done. 


PATHOLOGY    OF    LABOR  1 49 

If  not,  the  child  must  be  lessened  in  size  or  delivered  by  Caesarean 
section.' 

What  treatment  do  the  external  tumors  (edema,  thrombus,  and 
hernia)  require? 

1.  When  edema  of  the  labia  is  extensive  enough  to  obstruct  delivery, 
a  number  of  punctures  should  be  made  with  a  fine  bistoury,  which 
will  speedily  drain  and  remove  it. 

2.  A  large  thrombus  occasionally  distends  the  labium  obstructively. 
A  free  incision  should  be  made,  the  clot  turned  out,  and  hemostatics 
applied,  if  necessary. 

3.  Hernia  rarely  complicates  labor.  If  irreducible,  it  requires  avoid- 
ance of  bearing  down. 

What  is  the  most  common  classification  of  contracted  pelvis? 

1.  The  pelvis  (squabiliter  justo  minor,  or  generally  contracted  pelvis, 
in  which  all  the  diameters  are  equally  contracted.  The  pelvis 
cBguabiliter  justo  major,  in  which  all  the  diameters  are  enlarged. 

2.  The  flattened  pelvis,  in  which  the  conjugate  diameter  especially 
is  diminished.     The  other  diameters  may  be  normal. 

As  subdivisions  of  the  last  we  have: 

(A)  Simple  flattened,  in  which  only  the  conjugate  is  decreased 
in  size.     This  is  the  most  frequent  form  of  pelvic  contraction. 

(B)  Generally  flattened,  in  which  the  narrowing  extends  also 
to  the  transverse  diameter. 

(C)  Rachitic  flat.  The  diameter  between  the  anterior  su- 
perior spines  is  equal  to,  or  greater  than,  the  distance  be- 
tween the  highest  points  of  the  iliac  crests.  In  this  type  of 
pelvis  the  greatest  contraction  occurs  in  the  antero-posterior 
diameter  of  the  inlet;  the  oblique  diameters  may  also  share 
in  the  contraction,  sometimes  one  more  than  the  other. 

3.  The  obliquely  contracted  pelvis,  principally  caused  by  spinal  curva- 
ture, hip  disease,  or  coxalgia,  by  a  non-symmetry  of  the  sacrum. 
One  oblique  diameter  is  usually  decreased.  Sometimes  the  other 
is  increased.  Occasionally  both  oblique  diameters  are  diminished 
in  size. 

4.  The  funnel-shaped  pelvis,  produced  by  posterior  curvature  or 
kyphosis  of  the  lumbar  spine.  The  conjugate  is  lengthened  and 
the  transverse  diameter  diminished. 

5.  The  compressed  pelvis  resulting  from  rachitis,  or  osteomalacia. 

6.  Spondylolisthetic  pelvis,  narrowing,  especially  of  the  antero-posterior 


ISO 


COMPEND    OF   OBSTETRICS 


diameter  of  the  inlet,  caused  by  a  slipping  forward  of  the  last  lumbar 
vertebra  upon  the  sacrum. 
7.  Pelvis  narrowed  by  exostoses,  fractures,  etc. 


What  is  scoliosis? 

Lateral  curvature  of  the  spine.     It  may  only  impair  one  side  of 
the  pelvis,  but  if  great,  may  cause  serious  deformity. 

What  effect  may  the  justo  major  pelvis  have  on  labor? 

Usually  labor  is  terminated  quickly.     Comphcations  may  arise, 


PATHOLOGY    OF    LABOR 


151 


however,  from  the  fetus  turning  transversely,   or  from  precipitate 
labor. 

What  effect  may  the  justo  minor  pelvis  have  on  labor? 

If  the  child  and  pelvis  are  proportionate  in  size,  labor  goes  on  as 
usual,  but  in  ordinary  cases  the  labor  begins  when  the  head  is  at  the 


Fig.  58. — Rachitic  Flat  Pelvis  with  Asymmetry  and  DoublePromontory. 

{Winckel.) 


Fig.  59. — Osteomalacic  Pelvis. — (Winrkel.) 

superior  strait,  strong  flexion  occurring.     The  biparietal  diameter  is 
in  relation  with  the  conjugate. 

Describe  the  rachitic  flat  pelvis  and  its  effect  on  labor. 

All  the  individual  parts  are  decreased  in  size;  the  sacrum  is  pushed 


152 


COMPEND    OF   OBSTETRICS 


forward  and  downward;  the  vertebras  are  pushed  forward  between  the 
wings.  Usually,  the  venters  of  the  ilia  are  inclined  more  strongly 
toward  the  horizon,  separate  more  anteriorly,  and  are  less  curved. 
The  result  of  this  is  that  the  distance  between  the  anterior  superior 
spines  is  as  great,  or  greater,  than  that  between  the  highest  points  of 
the  iliac  crests.  The  pubic  arch  is  widened  and  the  pelvic  cavity 
kidney-shaped.  If  the  head  presents,  the  sagittal  suture  lies  in  the 
transverse  diameter.     The  head,  instead  of  entering  the  pelvic  cavity 


Pig.  6o. — Obliquely  Deformed  Pelvis  from  Coxalgia. — (Edgar.) 

Sit  the  latter  part  of  pregnancy,  may  be  turned  aside  at  the  superior 
strait.  The  transverse  diameter  of  the  fetal  head  is  in  relation  with 
the  conjugate,  the  anterior  parietal  bones  becoming  a  fixed  pivot 
against  the  pubic  arch,  while  the  posterior  descends  beneath  the  prom- 
ontory. An  attempt  is  made  to  produce  extreme  flexion.  After  the 
head  has  descended  into  the  pelvic  cavity,  labor  proceeds  in  the  usual 
way. 


PATHOLOGY    OF    LABOR  153 

Describe  the  principal  characteristics  of  the  osteomalacic  pelvis. 

In  this  form  of  deformity  softening  of  the  bones  has  cau-sed  the  bend- 
ing inward  of  the  anterior  half  of  the  pelvis,  bringing  the  two  pubic 
rami  very  near  together  in  the  form  of  an  irregular  beak  or  projection. 
Indications  of  osteomalacia  will  probably  appear  in  other  parts  of  the 
body.     The  disease  may  make  its  appearance  during  pregnancy. 

Describe  the  deformity  resulting  from  coxalgia. 

The  narrowing  is  principally  oblique.  In  unilateral  hip  disease, 
the  diseased  femur  is  much  decreased  in  size;  the  diseased  hip  is  pushed 
out  from  the  symphysis  and  its  anterior  half  is  more  arched.  From 
the  inactivity  of  the  glutei  muscles  and  the  increased  action  of  the 
iliacus  internus,  the  ilium  is  more  vertical  than  usual,  the  healthy  half 
of  the  pelvis  is  flattened  and  narrowed,  the  diseased  half  is  hollowed 
out  and  dilated. 

Do  deformities  of  the  inlet  affect  the  whole  course  of  delivery? 

Generally  the  trouble  is  over  when  the  head  has  passed  through 
the  inlet,  the  rest  of  the  pelvis  being  undeformed. 

What  effect  upon  delivery  is  occasioned  by  deformities  of  the  inlet? 

1.  The  presentation  is  apt  to  be  irregular. 

2.  The  agreement  between  the  axes  of' the  uterus  and  pelvis  being 
disarranged,  the  uterine  force'  is  deflected,  which  protracts  both 
the  first  and  second  stages. 

3.  The  normal  mechanism  of  delivery  is  perverted. 

4.  The  inlet  is  made  too  small  to  admit  of  the  child  passing  readily. 

5.  The  maternal  tissues  are  more  apt  to  suffer  from  pressure  due  to 
the  misdirection  of  the  uterine  force. 

In  what  way  is  the  mechanism  altered? 

1.  The  head  is  usually  more  transversely  placed,  and  rotation  has  to  be 
made  through  a  longer  arc. 

2.  The  head  has  to  make  a  curved  passage  around  the  promontory 
before  it  can  enter  the  inlet. 

3.  The  narrowing  of  the  pelvis  delays  the  head  until  it  can  be  com- 
pressed and  molded  to  a  suitable  size. 

How  are  degrees  of  deformity  estimated? 

By  the  length  of  conjugate  diameter,  as  determined  by  pelvimetry. 

What  degree  of  contraction  is  compatible  with  delivery? 

Much  will  depend  upon  the  skill  of  the  physician,  but  in  general 


154  COMPEND    OF    OBSTETRICS 

terms  it  may  be  said  that  with  a  conjugate  of  3  inches  or  more,  a 
living  child  may  be  extracted,  with  or  without  the  forceps;  3  to 
21/2  inches,  may  be  delivered  by  forceps  or  version,  or  at  worst  by 
craniotomy;  two  and  a  half  or  less,  may  be  delivered  by  craniotomy, 
but  the  statistics  show  that  the  Caesarean  section  is  much  safer. 
(Parry.) 

At  the  present  time  a  diameter  of  3  inches  or  7  +  centimeters  or  less 
would  be  an  indication  for  abdominal  Caesarean  section. 

How  would  we  ascertain  the  condition  of  a  woman's  pelvis? 

1.  By  her  history:  as  to  rickets  in  childhood;  the  time  of  dentition; 
when  the  latter  is  late,  it  is  a  sign  of  imperfect  bone  formation. 
The  shape  of  the  head.     By  careful  examination  of  the   patient's 

body. 

2.  The  history  of  previous  labors.  Continued  prolonged  labors 
should  cause  a  suspicion  of  pelvic  deformity; 

3.  By  inspection  of  the  patient's  external  appearance  in  regard  to 
deformities  in  locomotion,  etc. ; 

4.  External  pelvimetry.  The  external  measurements  taken  from 
certain  fixed  landmarks  on  the  living  pelvis,  by  an  instrument 
known  as  a  pelvimeter,  are  generally  classed  as  certain  signs. 
These  measurements  should  be  taken  with  the  patient  on  her 
back,  preferably  on  a  table,  and  covered  with  a  sheet.  The 
head  and  shoulders  should  be  raised  and  the  knees  flexed. 

What  are  the  anatomical  landmarks  from  which  these  measure- 
ments are  taken? 

Between  the  anterior  superior  spinous  processes  of  the  iliac  bones; 
the  distances  between  the  iliac  crests,  the  inter- trochanteric  and  the 
external  conjugate.  In  measuring  the  above  the  physician  should 
stand  by  the  side  of  the  patient,  and  holding  the  pelvimeter  between 
the  thumb  and  fingers,  the  points  should  be  applied  to  the  outer  sides 
of  the  points  above  mentioned.  In  measuring  the  external  conjugate, 
the  patient  should  lie  on  her  side  with  her  face  away  from  the  physician. 

Between  anterior-superior  I 10  1/4  inches  or  26  cm. 

spines,  j 

Between  the  highest  points  of  \  _   _         j  j  inches  or  28  cm. 

the  iliac  crests,            J 
Between  trochanters, 12  1/4  inches  or  32  cm. 


PATHOLOGY    OF    LABOR 


155 


Between  what  anatomical  points  are  the  diagonal  diameters  of  the 
pelvic  inlet  taken  externally? 

The  right  obHque  or  diagonal  is  taken  from  the  right  posterior- 
superior  spine  of  the  ilium  to  the  left  anterior-superior  spine  of  the 
same  and  measures  87/8  inches  or  22  1/2  centimeters;  the  left  oblique 
or  diagonal  from  the  left  posterior  spine  of  the  ilium  to  right  ante- 
rior-superior spine  of  the  same  and  measures  8  5/8  inches  or  22 
centimeters. 

Between  what  anatomical  points  is  the  external  conjugate  of  the 
pelvic  inlet  taken? 

The  external  conjugate,  is  taken  from  the  fossa  just  beneath  the 
spinous  process  of  the  last  lumbar  vertebra  to  the  middle  of  the  upper 


Fig.  61. — Pelvimeters. 


border  of  the  anterior  surface  of  the  symphysis  pubis.  It  is  about 
81/4  inches  or  20.5  centimeters.  This  is  also  sometimes  spoken  of 
as  Baudelocque's  diameter,  from  its  author. 

How  may  the  internal  conjugate  be  measured? 

By  subtracting  31/2  inches,  or  9  centimeters,  from  the  external 
conjugate.  This  is  the  allowance  for  the  soft  parts,  sa'  rum,  and 
pubes.  Thus  the  remainder,  41/2  inches,  or  11.5  centimrters,  is  the 
average  length  of  the  internal  conjugate,  or  conjugata  vera.  To 
measure  this,  one  or  two  fingers  of  a  well-asepticized  hand  should 
be  passed  into  the  vagina  and  extended  so  as  to  reach  the  sacral  prom- 
ontory. The  point  at  which  the  anterior  commissure  of  the  vulva 
(really  the  undersurface  of  the  pubic  joint  anterior  surface)  touches 
the  hand  may  then  be  noted  and  the  reach  measured.  This  is  the 
diagonal  conjugate  or  sacro  sub-pubic  diameter.  It  measures  13.5 
centimeters  or  5  1/4  inches.  Deduct  i  inch  (2.4  centimeters)  from 
II 


156 


COMPEND    OF    OBSTETRICS 


this  for  the  thickness  of  the  pubes,  and  we  have  the  true  or  internal 
conjugate  of  11.5  centimeters  or  4  1/2  inches. 

In  the  normal  pelvis,  or  where  a  very  slight  degree  of  contraction 
exists,  the  promontorj'-  cannot  be  reached. 

In  what  other  way  may  the  relation  between  the  fetal  head  and  the 
pelvic  inlet  be  ascertained? 

By  pressing  the  head  into  the  pelvic  brim  by  external  manipulation 


Fig.  62. — Measuring  the  True  Conjugate  of  the  Pelvic  Inlet  with  the 
Skutsch  Pelvimeter. — {Edgar.) 

How  is  this  done? 

The  woman  lying  on  her  back  with  the  thighs  somewhat  flexed, 
the  physician  should  palpate  the  head  to  ascertain  its  exact  position; 
then  gently  grasping  the  neck  with  one  hand  and  making  firm  yet 
gentle  pressure  on  the  breech  with  the  other,  in  a  direction  downward 
and  backward  as  the  patient  lies,  the  head  will  be  felt  to  slip  into  the 
pelvic  cavity,  providing  the  pelvic  inlet  is  large  enough  to  admit  of 


OVULAR   DYSTOCIA  1 57 

its  doing  so.  The  space  between  the  head  and  the  pubic  bone  can  be 
approxiinated  by  laying  the  hands,  thumbs  together  on  the  abdomen 
and  gently  pressing  the  fingers  between  the  head  and  the  pubic  joint. 
In  doing  this  the  physician's  back  must  be  toward  the  patient's  head 
and  his  finger  tips  toward  the  pubic  joint. 

What  are  the  principal  diameters  of  the  pelvic  cavity? 

It  has  an  antero  posterior  and  transverse  diameters.  The  first  is 
taken  from  the  junction  of  the  second  and  third  pieces  of  the  sacrum  to 
the  middle  of  the  posterior  surface  of  the  pubic  joint.  Its  average 
diameter  is  12.75  centimeters. 

Attempts  to  measure  the  relative  size  of  the  fetus  and  pelvis  have 
been  made  by  the  use  of  the  X-ray.  Various  instruments  have  also 
been  devised  for  this  purpose.      (See  Fig.  62) 

"What  are  the  principal  diameters  of  the  pelvic  outlet  and  how  may 
they  be  measused? 

1.  An  antero  posterior;  taken  from  the  tip  of  the  coccyx  to  the 
inferior  surface  of  the  pubic  point.  It  measures  9.5  centimeters 
or  about  33/4  inches. 

2.  A  transverse  taken  from  the  center  of  the  ischial  tuberosities.  It 
measures  10  centimeters  or  4  inches. 

How  may  the  outlet  be  deformed? 

By  a  narrowing  of  the  transverse  diameter,  due  to  a  too  close 
approach  of  the  ischia;  or  of  the  conjugate  diameter,  due  to  ankylosis 
or  rigidity  of  the  sacro- coccygeal  joint.  The  first  is  rare,  and  the 
second  common  in  old  primiparae. 

What  treatment  is  indicated? 

The  treatment  would  depend  entirely  on  the  extent  of  the  deformity. 
Frequently  the  head  may  be  extracted  by  forceps,  but  if  the  contrac- 
tion is  discovered  before  labor  and  is  normal  it  is  better  to  deliver  the 
child  by  abdominal  section. 

OVULAR  DYSTOCIA 

What  departures  from  the  normal  condition  occur  in  connection 
with  the  fetus  and  its  envelopes? 

I.  The  membranes  (a)  may  rupture  prematurely;  (b)  may  be  too 
tough;  (c)  there  may  be  an  extra  amniotic  sac;  (d)  there  may  be 
hydrops  amnii. 


158  COMPEND   OF   OBSTETRICS 

2.  The  funis  (a)  may  prolapse;  (6)  may  be  too  short. 

3.  The  child  may  be  enlarged  or  deformed  by  (a)  hydrocephalus; 
(b)  hydrothorax;  (c)  ascites;  (d)  edema;  (e)  putridity;  (/)  by  anky- 
losis of  joints;  (g)  various  fetal  tumors. 

4.  Parts  of  the  child  may  be  displaced:  (a)  prolapse  of  arm  or  foot 
by  head;  (b)  arm  behind  the  occiput. 

5.  There  may  be  more  than  one  child,  called  multiple  labor. 

What  effect  has  the  premature  rupture  of  the  membranes? 

1.  No  bag  of  waters  is  formed  to  assist  in  dilating  the  os. 

2.  The  uterine  walls  close  upon  the  irregular  projections  of  the 
child,  instead  of  upon  the  evenly-pressing  water-sac,  and  irregular 
contractions  may  occur. 

3.  The  first  stage  is  prolonged. 

4.  The  child  is  subjected  to  greater  pressure,  and  may  be  injured. 

What  harm  is  occasioned  by  too  thick  membranes? 

Hours  may  elapse  before  the  uterus,  unaided,  can  rupture  the 
membranes,  and  during  this  time  the  patient  may  become  exhausted. 
Artificial  rupture  should  be  resorted  to  in  this  condition. 

What  is  a  "caul"? 

In  rare  cases,  where  there  is  little  liquor  amnii  and  the  mem- 
branes are  elastic,  the  child  is  born  with  its  head  enveloped  in  the 
membranes,  which  is  called  being  born  with  a  caul,  [The  mem- 
branes, when  dried  and  preserved,  are  said  to  be  a  charm  against 
death  by  drowning.]  The  practical  point  is  to  tear  or  cut  open  the 
sac  as  soon  as  possible,  to  prevent  asphyxia  of  the  child. 

What  is  an  extra-amniotic  sac? 

An  effusion  or  secretion  of  fluid  which  sometimes  occurs  between 
the  amnion  and  chorion.  When  the  bag  of  waters  is  formed  during 
labor,  the  sac  will  be  formed  by  this  fluid,  and  when  the  chorion  is 
ruptured  the  fluid  will  escape,  giving  the  impression  that  the  true  bag 
of  waters  has  ruptured.  A  new  bag  will  then  form,  enclosed  only  in  the 
amnion.     It  is  of  no  importance,  except  in  the  matter  of  diagnosis. 

What  is  hydrops  amnii? 

Dropsy  of  the  amnion  or  over-secretion  of  fluid  by  the  amnion. 
This  may  take  place  to  the  extent  of  over  a  gallon,  distending  the 
uterus,  enfeebling  and  sometimes  destroying  the  child.  If  the 
amount  of  fluid  is  great,  it  is  well  to  pass  a  bandage  around  the 
abdomen  before  evacuating  it,  and  stimulants  should  also  be  at  hand. 


OVULAR   DYSTOCIA  1 59 

What  is  prolapse  of  the  funis? 

The  funis,  or  rather  a  loop  of  the  cord,  may  fall  in  advance  of  the 
head.  There  may  be  only  a  small  knuckle,  or  several  inches  may 
prolapse,  so  that  the  cord  even  reaches  to  the  vulva.  This  endangers 
the  child's  life,  from  pressure,  but  is  rarely  an  impediment  to  delivery. 

With  what  may  the  funis  be  confounded? 

With  a  loop  of  intestine,  which  also  may  be  met  with  after  rup- 
ture of  the  womb.  The  finger  may  be  pasesd  entirely  around  the 
funis;  with  the  intestine,  the  mesentery  will  prevent. 

What  treatment  is  indicated? 

The  funis  should  be  pushed  up  above  the  inlet  in  the  interval 
between  pains,  and  when  the  presentation  is  forced  down  by  a  con- 
traction, it  will  probably  be  retained.  This  can  be  done  by  the 
fingers  or  by  repositors  invented  for  the  purpose,  and  may  be  aided 
by  placing  the  woman  in  the  knee-chest  posture.  It  can  also  be  done 
by  carefully  placing  a  loop  of  cord  around  the  funis,  attaching  it  to  a 
moderately  hard  catheter,  and  pushing  it  gently  back  into  the  empty 
pelvic  diameter.  If  the  advance  of  the  presentation  does  not  retain 
it,  a  small  piece  of  gauze  passed  between  the  head  and  the  inlet  will 
often  succeed.  If  the  cord  is  surely  pulseless  it  may  be  let  alone,  but 
if  the  child  is  alive  and  the  funis  cannot  be  retained,  prompt  artificial 
delivery  is  indicated. 

In  what  way  does  a  short  funis  impede  delivery? 

By  preventing  the  child  from  descending  completely  through 
the  pelvis.  It  may  be  only  5  inches  long,  and  if  of  normal  length, 
may  become  shortened  by  being  wrapped  in  one  to  four  coils  around 
the  child's  neck. 

How  may  a  short  funis  be  recognized  during  labor? 

1.  The  head  is  arrested  low  in  the  pelvis;  it  then  advances  slightly 
with  each  contraction,  and  is  abruptly  jerked  back  by  the  tension 
of  the  cord. 

2.  Constant  pain  is  felt  in  the  womb,  over  the  placental  insertion. 
Fortunately,  the  occurrence  is  rare,  since  the  diagnosis  is  not 
easy  unless  the  head  is  born,  and  aid  is  difficult  to  render.  ' 

What  treatment  is  required? 

Delivery  by  main  force  until  the  cord  can  be  reached  and  cut, 
or  is  ruptured. 


l6o  COMPEND    OF    OBSTETRICS 

What  is  hydrocephalus? 

Enlargement  of  the  fetal  head  by  excessive  development  of  the 
cerebrospinal  fluid.  It  may  be  so  great  as  to  double  the  length  of 
the  head  diameters.  The  bones  are  thin  (in  extreme  cases  expanded 
and  parchment-like  in  texture) ,  and  the  sutures  and  f  ontanelles  greatly 
enlarged.     It  is  often  associated  with  spina  bifida. 

How  may  it  be  recognized? 

By  the  softness  of  the  head  and  the  enlargement  of  the  sutures 
and  fontaneUes.  Moderate  degrees  are  not  recognized  with  certainty 
until  the  forceps  are  applied,  when  the  wide  divergence  of  the  handles 
shows  the  increased  bulk  of  the  head. 

How  should  it  be  managed? 

In  head-first  labors  simple  perforation  of  the  skull  will  allow  the 
fluid  to  escape,  and  permit  the  collapsed  cranium  to  be  withdrawn. 
The  brain  should  also  be  broken  up  before  the  child  is  withdrawn. 
In  head-last  labors  it  is  generally  best  to  open  the  spinal  canal  between 
the  shoulders,  and  by  means  of  an  elastic  catheter  draw  off  the  fluid. 
After  this  the  skull  can  be  crushed  and  extracted.  Some  authorities 
recommend  decapitation  before  attempting  to  deliver  the  head. 

How  may  hydrothorax  and  other  enlargements  of  the  fetus  obstruct 
delivery? 

Effusion  of  serum  in  the  chest  (hydrothorax),  abdomen  (ascites), 
external  cellular  tissue  (edema),  may  enlarge  the  bulk  of  the  child 
and  obstruct  delivery.  The  joints  may  be  ankydosed  in  such  a  posi- 
tion as  to  increase  its  bulk.  A  child  dying  in  utero  and  becoming  pu- 
trid may  be  swollen,  but  usually -causes  trouble  only  by  poisoning  the 
mother. 

In  any  of  these  cases  it  may  be  necessary  to  reduce  the  bulk  of  the 
child   by   embryotomy. 

How  is  prolapse  of  the  hand  or  arm  by  the  head  to  be  treated? 

The  prolapsed  member  is  to  be  pushed  up,  as  in  the  case  of  prolapse 
of  the  funis.  If  the  arm  is  behind  the  head  and  the  diagnosis  can  be 
made,  turning  is  indicated. 

In  what  way  may  the  foot  or  feet  complicate  head  presentations? 

One  or  both  feet  may  presen  alongside  of  the  head,  in  which  case 
the  child  must  be  more  or  less  doubled  up.  It  may  be  noticed  that 
these  accidents  often  occur  together,  feet,  arms,  and  funis,  in  varying 
proportions,  prolapsing  at  the  same  time. 


TWIN   LABOR  l6l 

How  is  the  complication  to  be  treated? 

If  recognized  before  the  rupture  of  the  membranes,  the  feet  may 
either  be  pushed  up  or  the  child  turned.  If  at  any  time  we  find 
turning  to  be  very  difficult  or  impossible,  we  may  know  that  the 
child  is  dead  (because  difficult  to  turn  and  doubled),  and  at  once 
perform  embryotomy. 

How  may  the  shoulders  give  trouble  in  delivery? 

By  not  entering  the  pelvis,  but  catching  at  the  inlet,  thus  prevent- 
ing the  head  from  advancing. 

How  may  this  be  recognized  and  treated? 

By  the  manner  in  which  the  head  advances  and  is  retracted,  as  in 
the  case  of  a  short  funis,  and  by  external  palpation.  By  external 
pressure  the  shoulders  may  be  pushed  into  their  proper  place. 

TWIN  LABOR 

How  can  twin  pregnancies  be  diagnosticated? 

The  diagnosis  *s  often  difficult,  but  generally  can  be  determined 
by  hearing  two  distinct  fetal  heart-sounds,  and  fetal  movements  are 
stronger.  By  palpation,  two  fetal  forms  can  be  made  out.  The 
abdomen  is  much  swollen;  there  is  considerable  bulging  at  each  side. 
Sometimes  a  well-marked  depression  or  sulcus  occurs  in  the  median 
line. 

What  is  the  usual  course  of  twin  labor? 

After  the  first  child  is  born  a  short  rest  occurs;  the  pains  recur 
(usually  within  fifteen  minutes)  and  the  second  child  is  born,  and  so 
on,  if  more  than  two. 

What  difficulties  may  occur  in  twin  labor? 

1.  Both  children  may  attempt  to  enter  the  pelvis  at  once,  and  become 
wedged. 

2.  After  one  head  has  reached  the  outlet,  the  second  may  enter  the 
pelvis,  with  the  same  result. 

3.  Head  locking  may  occur. 

What  is  head  locking? 

When  the  first  child  is  born  by  the  breech,  its  chin  may  catch  upon 
the  chin  of  the  second  child,  presenting  by  the  head. 


l62  COMPEND    OF    OBSTETRICS 

What  general  rules  may  be  laid  down  for  these  complications? 

1.  To  push  up  one  child  and  allow  the  other  to  come  down,  if  possible. 

2.  When  one  child  is  partially  born  and  the  other  wedged  in  with  it, 
the  first  child  is  to  be  sacrificed  in  order  to  save  the  second. 

What  are  the  fetal  appendages  in  multiple  pregnancies? 

If  the  pregnancy  results  from  the  fecundation  of  one  ovule  contain- 
ing two  germinal  vesicles,  or  a  single  germ  dividing  into  two,  there  is 
a  single  placenta  and  communicating  vessels.  In  these  cases  but  one 
chorion  exists;  generally  each  child  has  its  own  amnion.  Whe  the 
development  results  from  the  impregnation  of  two  ovules,  the  vessels 
of  the  placenta  do  not  connect.  In  these  cases  each  fetus  has  its  own 
chorion  and  amnion.  Early  in  development  a  separate  ovular  decidua 
exists  for  each.  Later,  through  absorption  of  the  dividing  membrane, 
there  is  but  one  decidua  for  both. 

What  form  of  twin  monsters  complicate  delivery? 

The  principal  forms  are — 

1.  Two  nearly  separate  bodies  united  in  front  by  the  thorax  or  ab- 
domen (ex.,  Siamese  twins). 

2.  Two  nearly  separate  bodies,  united  back  to  back  by  the  sacrum 
and  lower  part  of  spinal  column  (ex..  North  Carolina  sisters). 

3.  Dicephalous  monsters;  the  bodies  single  below,  but  the  heads 
separate. 

4.  The  bodies  separate,  but  the  heads  are  partially  united. 
The  two  latter  are  almost  invariably  still-born.     (Playfair.) 

EFFECT  OF  MATERNAL  CONDITIONS  ON  LABOR 

What  maternal  conditions  may  affect  labor? 

I.  Syncope.  2.  Hemorrhage.  3.  Rupture  of  the  uterus.  4.  Eclamp- 
sia. 

How  does  syncope  affect  labor? 

Usually  by  only  temporarily  suspending  the  uterine  contractions. 
If  associated  with  organic  heart  disease  it  may  prove  fatal.  The  treat- 
ment is  the  same  as  indicated  at  any  other  time. 

What  forms  of  hemorrhage  are  met  with? 

I.  From,  detachment  of  a  normally  implanted  placenta,  before  or 
during  the  birth  of  the  child,  or  accidental  hemorrhage.  (See 
Pathology  of  Pregnancy.) 


POST-PARTUM   HEMORRHAGE  1 63 

2.  From  detachment  of  abnormally  implanted  placenta,  before  the 
birth*  of  the  child,  or  unavoidable  hemorrhage.  -(See  Pathology  of 
Pregnancy.) 

3.  During  and  after  the  third  stage,  or  post-partum  hemorrhage. 

POST-PARTUM  HEMORRHAGE 

What  is  post-partum  hemorrhage? 

It  is  hemorrhage  from  any  portion  of  the  parturient  canal  after 
delivery  of  the  fetus.     Properly  it  is  only  from  the  placental  site. 

It  is  primary  or  immediate  when  it  occurs  within  24  hours  after  the 
birth  of  the  child. 

It  is  secondary  or  remote  when  it  occurs  any  time  during  the  puerperal 
period  after  the  first  24  hours.  It  is  much  more  common  in  multi- 
paras than  primiparae. 

What  is  the  cause  of  hemorrhage  post-partum? 

The  immediate  cause  is  an  uncontracted  or  incompletely  contracted 
uterus,  whereby  the  opened  sinuses  of  the  placental  site  are  not  com- 
pressed and  bleeding  is  allowed.  It  is  favored  by  the  retention  of  the 
placenta,  clots  (incomplete  delivery),  and  by  fibroid  tumors.  In  a 
slight  form,  may  be  due  to  laceration  of  the  cervix,  vagina,  and  peri- 
neum. As  exciting  causes:  i.  Improper  treatment  of  the  second  and 
third  stages  of  labor.  2.  Forcible  extraction  of  breech  presentat'on. 
3.  Too  rapid  emptying  of  the  uterus  by  forceps.  4.  Use  of  anesthetics. 
5.  Mental  emotion.  6.  Placenta  praevia.  7.  Diseases  of  the  pelvic 
organs.  8.  Exhaustion  following  a  hard  labor.  9.  Constitutional 
diseases. 

As  predisposing  causes:  Any  condition  causing  blood  changes, 
such  as;  Malaria,  Toxemia  of  pregnancy.  Hemophilia,  Malpositions 
of  the  uterus.  Tumors,  Hydramnios. 

What  are  the  symptoms  of  post-partum  hemorrhage? 

1.  Usually  the  blood  pours  out  so  freely  as  to  readily  attract  atten- 
tion; if  concealed  or  retained  in  the  uterus,  it  will  occasion  the  symp- 
toms of  internal  hemorrhage. 

2.  The  hand  placed  on  the  abdomen  will  not  find  the  womb  hard  and 
in  the  hypogastric  region,  but  soft  and  at  a  higher  level. 

What  are  the  indications  for  treatment? 

Preventative. 

Treat  during  pregnancy  all  conditions  which  predispose  to  post- 


164  COMPEND    OF    OBSTETRICS 

partum  hemorrhage,  and  in  such  cases  delay  rather  than  hurry  the 
second  and  third  stages  of  labor.     Keep  the  uterus  well  contracted 
after  labor  by  manual  compression  and  ergot  and  tonic  doses  of 
strychnin.     A  good  tight  abdominal  binder  will  aid  in  this.^ 
Curative. 

1.  To  empty  the  womb. 

2.  To  make  the  womb  contract. 


Fig.  63. — Momburg's  Belt   Constriction  for  the  Control  of  Uterine  Hem- 
orrhage.— (Bumm.) 

3.  To  cause  clots  in  the  opened  sinuses,  if  the  womb  fails  to  contract. 

4.  To  support  the  woman's  strength. 

How  is  this  treatment  to  be  carried  out? 

1.  The  hand  should  be  introduced  into  the  womb,  and  clots  or  other 
^  contents   removed. 

2.  One  hand  is  reintroduced  and  moved  about,  stroking  the  uterine 
walls,  while  the  other  hand  is  similarly  engaged  on  the  abdomen. 


POST-PARTUM   HEMORRHAGE  1 65 

This  will  often  succeed  in  arousing  contractions,  and  lead  to  the 
expulsion  of  the  hand  from  the  womb.     If  not, 

3.  Injections  of  sterile  hot  water  (105°  F.)  may  be  used  or  alternate 
injections  of  hot  and  cold  water,  or  ice. 

4.  A  strip  of  new  aseptic  gauze  may  by  means  of  dressing  forceps 
be  inserted  into  the  uterus  as  far  as  the  fundus  and  loosely  packed, 
another  strip  being  placed  in  the  vagina  until  it  is  full. 

5.  A  handerkchief,  soaked  in  vinegar,  may  be  carried  into  the  womb 
and  squeezed  out;  or  a  peeled  lemon;  or  a  piece  of  ice. 

6.  The  faradic  current  may  be  useful,  if  at  hand. 

7.  As  a  last  resort,  and  to  cause  clots,  injections  of  tincture  of  iodin, 
or  solution  of  ferric  chlorid,  diluted  one-third,  or  even  of  full 
strength,  may  be  used. 

8.  Compression  of  the  abdominal  aorta. 

9.  Use  of  the  Momburg  belt. 

How  may  post-partum  hemorrhage  from  inertia  be  prevented? 

By  delivering  the  placenta  by  the  method  of  Cred6  and  by  the 
preventive  treatment  before  mentioned. 

What  internal  medication  is  proper  to  combat  the  constitutional 
affects  of  hemorrhage? 

Stimulants,  hypodermics  of  strychnin  sulph.  grs.  1/40-1/20,  or  ergot 
5j;  these  may  be  repeated.  f§j  each  of  strong  coffee,  whisky  and 
normal  salt  solution  may  be  given  by  the  rectum  and  repeated.  Saline 
transfusion  or  hypodermoclysis  or  both  should  be  resorted  to.  lUx  of 
a  I  :  1000  solution  of  adrenalin  chloride  given  by  hypodermic  is  often 
of  use.  The  foot  of  the  patient's  bed  should  be  raised  2  or  3  feet  from 
the  floor. 

What  is  the  operation  of  transfusion? 

Injecting  into  the  circulation  blood,  milk,  or  solution  of  sodium 
chlorid,  in  strength  of  0.6  per  cent,  (normal  salt  solution).  To 
inject  blood  requires  special  and  costly  apparatus  and  great  skill. 
Normal  salt  solution  may  be  injected  with  little  trouble.  Care 
must  be  taken  to  avoid  injecting  air,  and  not  to  inject  so  rapidly 
as  to  distend  the  right  side  of  the  heart. 

What  is  secondary  hemorrhage  and  its  cause? 

Hemorrhage  occurring  after  an  interval  of  several  hours,  or  even 
days,  after  delivery.     It  is  usually  preceded  by  ordinary  post-partum 


l66  COMPEND    OF    OBSTETRICS 

hemorrhage,  and  may  be  due  to  a  return  of  uterine  inertia;  the  detach- 
ment of  thrombi,  retention  of  pieces  of  membrane,  or  clots;  dis- 
placement of  the  uterus,  from  a  too  tight  bandage;  an  impacted  rec- 
tum; sitting  up  too  soon  or  depressing  mental  emotions. 

What  treatment  is  indicated? 

The  same  in  principle  as  in  immediate  hemorrhage,  with  due 
attention  to  the  exciting  cause. 

RUPTURE  OF  THE  UTERUS 

What  is  rupture  of  the  uterus? 

A  tear  or  laceration  in  the  substance  of  the  uterine  bod}^,  usually 
permitting  the  escape  of  the  child  into  the  abdominal  cavity. 

How  frequently  does  it  occur? 

About  once  in  4000  labors. 

Under  what  circumstances  does  it  occur? 

Generally  during  the  second  stage  of  labor,  the  rent  beginning 
in  the  cervix  and  extending  toward  the  fundus.  Rarely  the  perit- 
oneal covering  escapes  laceration.  Rupture  of  the  uterus  occasionally 
occurs  early  in  the  labor,  or  even  in  premature  labors. 

What  are  the  predisposing  causes  of  rupture? 

Abnormal  presentation,  a  hydrocephalic  head,  prolonged  parturi- 
tion, a  degeneration  of  the  muscular  fibers  of  the  uterus,  producing 
a  lack  of  contractile  power;  a  great  difference  in  proportion  between 
the  size  of  the  child  and  pelvis. 

How  is  the  uterus  affected? 

During  labor  there  is  a  tendency  for  the  anterior  wall  of  the  cervix 
to  be  pulled  upward,  and  for  the  posterior  wall  to  be  pushed  downward 
(D.  Berry  Hart).  If  the  head  becomes  packed  in  the  inlet  early,  so 
as  to  prevent  the  anterior  wall  of  the  cer^dx  from  being  pulled  up,  the 
anterior  wall  just  above  the  head  becomes  greatly  thinned,  owing 
to  this  upward  pulling,  and  rupture  almost  invariably  begins  at  this 
point.  The  thickened  ring  of  fibers  just  above  the  point  of  thinning 
is  known  as  Bandl's  ring. 

What  are  the  symptoms  of  threatened  rupture? 

A  rising  of  the  contraction  ring  of  Bandl;  this  can  be  felt,  can 
be  seen  in  some  cases,  high  up  near  the  umbilicus.     It  is  usually 


ECLAMPSIA  167 

higher  on  the  left  than  on  the  right  side.  Above  this  ring  the  uterine 
tissue  is  thickened,  while  below  it  the  womb  is  thin,  stretching  more 
and  more  as  labor  advances.  Intense  pain  in  the  pubis  or  abdominal 
region. 

What  symptoms  denote  its  occurrence? 

During  or  just  after  a  labor  pain  the  woman  is  seized  with  an  acute 
and  persistent  pain.  The  form  of  the  uterine  tumor  is  changed 
and  the  presentation  is  retracted.  As  blood  is  effused  from  the 
rent,  symptoms  of  internal  hemorrhage  and  shock  are  added.  The 
fingers  passed  into  the  vagina  readily  recognize  the  rent,  and  if  the 
child  has  altogether  escaped  into  the  abdominal  cavity  the  intestines 
will  have  prolapsed  through  the  rent.     The  uterine  contractions  cease. 

What  treatment  is  indicated? 

1.  Preventive;  a  prompt  resort  to  the  forceps  when  the  occurrence 
is  feared,  providing  the  child  and  pelvis  are  of  relative  size.  If, 
however,  the  pelvis  is  too  small  for  the  child  to  pass  through,  rup- 
ture of  the  uterus  can  be  prevented  only  by  delivery  by  abdominal 
section,   symphysiotomy,   or  craniotomy. 

2.  Afterward,  if  the  presentation  is  not  entirely  retracted,  an  attempt 
may  be  made  to  deliver  per  vias  naturales. 

3.  In  any  case,  unless  it  can  be  demonstrated  that  the  peritoneum  is 
unbroken,  the  abdomen  should  be  opened  by  an  incision,  the 
uterine  wound  closed  by  sutures,  all  blood  and  fluids  removed 
from  the  abdominal  cavity,  and  strict  antiseptic  precautions 
observed.  If  the  rent  in  the  uterus  is  severe,  hysterectomy  should 
be  done,  providing  the  patient  is  in  fairly  good  condition. 

What  is  the  mortality  from  rupture? 

1 .  In  cases  abandoned  to  nature,  nearly  all  die. 

2.  When  the  child  is  delivered  without  abdominal  section,  a  few  more 
recover. 

3.  When  abdominal  section  is  at  once  performed,  60-70  per  cent, 
recover. 

ECLAMPSIA 
What  is  eclampsia? 

A  form  of  convulsions  occurring  before,  during,  or  after  labor, 
which  resembles  epilepsy  in  clinical  appearance  and  uremic  convul- 
sions in  cause.  The  typical  form  occurs  during  the  second  stage 
of  labor. 


1 68  COMPEND    OF    OBSTETRICS 

What  is  the  clinical  history  of  an  attack? 

1.  The  patient  is  suddenly  seized  with  a  to7iic  spasm,  involving  the 
muscles  of  the  face  and  thorax,  usually  of  the  upper  extremities, 
and  occasionally  of  all  the  muscles.  This  tonic  spasm  lasts  for 
about  one  minute,  and — 

2.  It  is  succeeded  by  clonic  spasms  or  twitchings,  lasting  for  several 
minutes.     The  convulsions  subside  and — 

3.  Are  succeeded  by  coma,  with  stertorous  breathing.     The  patient 
may  become  conscious  or  the  convulsions  may  be  renewed  in  the 
same  order,  keeping  up  until  the  patient  is  exhausted  or  recovers. 
The   masseter   muscles   are   contracted   tonically   throughout   the 

seizure.  The  interference  with  respiration  causes  the  face  to  become 
red  or  livid.  The  duration  of  each  seizure  and  the  interval  between 
depend  upon  the  severity  of  the  attack. 

What  prodromic  symptoms  warn  us  of  an  attack? 

1.  Severe  and  persistent  headache  is  often  complained  of  before 
an  attack,  frequently  associated  with  disorders  of  vision,  such  as 
flashes  of  light.  There  is  frequently  also  persistent  substernal  pain 
or  distress. 

2.  Edema  of  the  lower  extremities  or  labia,  or  both,  accompanied 
by  any  of  the  above  symptoms,  whether  associated  or  not  with 
albumin  in  the  urine,  should  put  us  on  our  guard.  A  trace  of 
albumin,  however,  is  generaUy  present,  and  with  it  there  is  usually 
a  marked  decrease  in  urea.  The  pulse  tension  and  blood  pressure 
are  usually  increased. 

What  is  the  cause  of  puerperal  eclampsia? 

The  cause  is  complex,  but  may  be  summed  up  in  the  word  auto- 
intoxication, the  toxemia  arising  from  the  liver,  intestines,  kidneys 
and  possibly  .the  placenta.     Various  theories  have  been  given  such  as: 

1.  During  pregnancy  the  blood  becomes  deteriorated  (hydremic), 
and  the  ill-supplied  nerve  centers  become  more  irritable  or  convul- 
sible  (Barnes). 

2.  During  pregnancy  the  processes  of  ehmination  are  usually  defective : 

(a)  The  bowels  are  usually  constipated,  hence  toxins  are  absorbed 

from    these. 
(&)  The   liver   is   frequently    torpid    and    its   poison-destroying 

action   is   below   normal, 
(c)   Deficient  excretion  by  the  lungs. 


ECLAMPSIA  169 

(d)  Insufficient  excretion  through  the  kidneys. 
{e)  The  mother  is  not  only  excreting  toxins  formed  in  her  own 
,  body,  but  from  the  child's  as  well;  so  that  when  her  organs 
of  excretion  are  acting  poorly,  large  quantities  of  toxins  are 
retained. 
Therefore  the  nerve  centers  are  supplied  with  poisonous  or  irritating 
substances,  as  well  as  impoverished  blood. 

3.  Vascular  tension  is  increased  during  pregnancy,  and  especially 
during  labor,  which  intensifies  the  action  of  the  foregoing  factors. 

4.  During  labor  the  interference  with  the  cephalic  circulation  (from 
bearing  down,  etc.)  causes  hydremia  of  the  brain  and  of  the  nerve 
centers  especially  concerned  with  eclampsia. 

Which  of  these  factors  is  the  most  important? 

The  uremia,  as  shown  by  the  fact  that  50  per  cent,  of  eclamptics 
have  albumin  in  the  urine. 

Wherein  does  puerperal  eclampsia  differ  from  other  forms  of  con- 
vulsions? 

1.  In  hysteria  the  spasms  are  altogether  irregular  and  consciousness 
is  never  entirely  lost. 

2.  In  apoplexy  the  condition  of  the  coma  is  permanent,  and  there  is  a 
difference  in  the  size  of  the  pupils.  There  is  not  the  amount 
of  spasm. 

3.  In  epilepsy,  the  history  will  distinguish,  except  in  labor  in  epi- 
leptics, who  rarely  have  convulsions  during  parturition  (Parry). 
In  epilepsy  there  is  the  peculiar  cry. 

5.  Tetanus  in  a  pregnant  or  puerperal  patient  usually  shows  a  his- 
tory of  injury  or  infection.  The  type  of  convulsion'  is  tonic  only. 
Consciousness  is  preserved  as  a  rule.  The  convulsions  persist 
longer  and  usually  begin  in  the  muscles  of  the  jaw.  No  previous 
symptoms  pointing  to  the  toxemia.  Other  conditions  that  may 
possibly  simulate  to  a  certain  degree  are  strychnin  poisoning  or 
alcoholic  convulsions.  The  history  and  a  study  of  the  convulsion 
ought  to  settle  the  diagnosis. 

What  point  in  the  etiology  is  disputed? 

The  condition  of  the  brain,  as  to  anemia  or  hyperemia. 

Traube  and  Rosenstein  assert  that  hydremia  causes  edema  of 
the  brain,  which  in  turn  leads  to  anemia  from  pressure  upon  the 
capillaries  from  without.     Others  assert  that  anemia  of  the  brain 


170  COMPEND    OF    OBSTETRICS 

is  essential  in  eclampsia, .  and  that  the  base  of  the  brain  is  anemic, 
even  when  the  convolutions  are  hyperemic.  The  probable  cause  of 
the  convulsion  is  the  action  of  the  toxemia  on  the  nerve  centers  of  the 
brain  and  spinal  cord. 

What  effect  upon  the  cerebral  circulation  have  the  bearing-down 
efforts  of  the  second  stage,  when  eclampsia  mostly  occurs? 

The  cervical  veins  are  obstructed  and  blood  accumulates  in  the 
brain. 

Does  this  occur  when  eclampsia  takes  place  before  or  after  labor? 

Not  demonstrably;  and  in  these  cases  we  conclude  that  other 
factors  exist,  notably  uremia — or  a  distinct  toxemia,  from  various 
poisons  generated  in  increased  quantities  during  pregnancy,  the 
amount  of  which  is  too  great  for  elimination;  or,  that  the  elimina- 
tory  power  is  for  a  time  defective. 

What  treatment  should  be  employed  to  prevent  eclampsia? 

The  urine  of  women  in  the  last  weeks  of  pregnancy  should  always 
be  examined.  Should  the  symptoms  of  continued  headache,  flashes 
of  light,  albuminuria,  and  deficient  excretion  of  solids,  especially 
urea,  make  their  appearance,  the  patient  should  be  placed  on  a  diet 
nearly  or  entirely  of  milk  or  milk  foods,  bread,  and  fruit.  The  bowels 
must  be  opened  by  saline  cathartics  or  calomel.  Hot  baths  at  a 
temperature  of  90°  or  100°  F.  are  beneficial;  the  patient  should  re- 
main in  the  water  from  ten  to  fifteen  minutes,  and  be  well  rubbed 
with  a  coarse  towel  afterward.  If  symptoms  continue  after  a  fair 
trial  of  the  above  methods,  the  uterus  must  be  emptied. 

What  are  the  indications  for  treatment  in  puerperal  eclampsia? 

1.  To  excite  elimination  by  increasing  the  action  of  the  skin,  liver, 
bowels,  and  kidneys. 

2.  To  relieve  the  irritability  of  the  nerve  centers. 

3.  To  reduce  vascular  tension. 

4.  To  reduce  cerebral  hyperemia. 

What  treatment  should  be  employed  during  the  attack? 

I.  Ether  or  chloroform  may  be  given  to  control  the  convulsions  or 
a  hypodermatic  injection  of  1/2  grain  codein  or  1/4  grain  of  mor- 
phin  may  be  used.  XXV  to  XXX  grains  of  chloral  hydrate  may 
be  given  by  the  rectum.  A  towel  or  a  piece  of  wood  should  be 
placed  between  the  teeth  to  prevent  the  tongue  from  being  bitten, 
or  a  mouth-gag  may  be  used. 


MISCELLANEOUS    COMPLICATIONS  171 

2.  By  means  of  a  stomach-tube  wash  out  the  stomach  with  boracic 
acid  solution  or  a  solution  of  bicarbonate  of  soda  5ii  to  the  pint 
and  afterward,  through  the  tube  give  calomel,  grs.  v;  croton  oil,  gtt. 
ss.  Wash  out  the  bowel  by  means  of  a  rectal  tube  attached  to  a 
fountain  syringe.  It  is  well  first  to  use  a  thorough  purgative 
enema  such  as  sulphate  of  magnesium,  gii;  castor  oil,  gii;  glycerin, 
§i;  turpentine,*  3 ii;  soap  suds  to  make  i  quart.  This  should  be 
followed  shortly  by  an  anemia  of  2  to  4  quarts  normal  salt  solution. 
The  enteroclysis  of  normal  salt  solution  may  be  repeated  in  four  to 
six  hours. 

3.  A  hot  pack  may  be  used  to  promote  diaphoresis. 

4.  The  labor,  if  in  progress,  should  be  terminated  as  soon  as  pos- 
sible, without  violence.  If  the  cervix  be  soft  and  the  time  of  labor 
near,  the  membranes  may  be  ruptured  with  the  finger.  Labor  will 
probably  soon  start  up.  Eclampsia  under  some  circumstances 
would  be  an  indication  for  ■  abdominal  delivery  or  delivery  by 
vaginal  Csesarean  section. 

5.  Venesection,  as  the  quickest  and  most  powerful  means  of  reduc- 
ing the  vascular  tension,  cerebral  hyperemia,  and,  secondarily, 
the  nervous  irritability.  The  venesection  may  be  accompanied  or 
followed  by  hypodermoclysis,  or  intravenous  injection  of  normal 
saline  solution,  or  the  latter  may  be  used  alone. 

6.  Veratrum  viride  may  be  used  instead,  or  in  addition,  to  saline 
transfusion  if  there  is  time  to  wait  upon  its  action. 

What  drug  was  especially  used  before  the  discovery  of  chloral  and 
the  bromids? 

Opium,  which  relieves  the  irritability  of  the  nerve  centers. 

What  objections  exist  to  its  use? 

Some  believe  that  it  allays  nerve  irritability  at  the  expense  of  all 
other  indications;  when  the  kidneys  are  seriously  crippled  it  may 
itself  cause  death. 

MISCELLANEOUS  COMPLICATIONS 

What  complications  may  exist  during  or  after  the  third  stage  of 
labor,  besides  hemorrhage? 

I.   Placental   dystocia,    or   difficulties   in   delivering   the   placenta. 
2.  Inversion  of  the  uterus.     3.  Emphysema,  of  the  neck.     4.  Lacera- 
tion of  the  cervix,  vagina,  and  perineum. 
12 


172  COMPEND   OF   OBSTETRICS 

What  forms  of  placental  dystocia  occur? 

I.  Adherent  placenta.  2.  Hour-glass  contraction.  3.  A  placenta 
too  large.  4.  Clots  behind  an  inverted  placenta.  5.  Utero-placental 
vacuum.     6.  Placentas  succenturise  and  other  anomalies  of  form. 

What  is  adherent  placenta? 

The  term  is  properly  appHed  to  one  that  has  contracted  firm  ad- 
hesions to  the  uterine  wall,  from  inflammation  during  pregnancy. 
There  is  usually  a  history  of  fixed  pain  in  the  uterus.  This  is  rare, 
but  improper  traction  upon  the  cord  may  delay  the  separation  of  an 
otherwise  normal  placenta. 

How  is  adherent  placenta  to  be  treated? 

Pass  the  hand  into  the  uterus,  find  a  detached  edge  of  the  placenta, 
and,  by  a  sawing  motion  with  the  fingers  between  the  uterus  and 
placenta,  break  through  the  adhesions.  When  small  pieces  are  ad- 
herent, they  are  best  removed  by  means  of  the  douche  curet  of 
Braun,  in  the  way  described  under  "Abortion."  The  strictest  asepsis 
must  be  used  in  these  cases.  In  many  cases  it  is  much  better  to 
pack  the  uterus  with  gauze  following  a  thorough  intrauterine  douche. 
The  small  fragments  will  in  a  short  time  become  detached  and  will 
come  away  when  the  packing  is  removed. 

What  is  hour-glass  contraction? 

Irregular  or  tetanic  contraction  of  a  part  of  the  uterine  walls,  the 
rest  being  relaxed,  whereby  the  placenta  is  grasped  and  held  as  if 
in  a  sac.  It  may  be  compUcated,  if  not  caused,  by  adherence  of  the 
placenta. 

How  may  it  be  recognized? 

The  hand,  introduced  into  the  womb,  finds  apparently  a  second 
OS  internum  high  up,  caused  by  the  constriction  of  the  muscular 
fibers  of  the  womb  below  the  placental  site. 

How  is  it  to  be  overcome? 

The  fingers,  little  by  little,  and  finally  the  hand,  are  to  be  insinuated 
within  the  constricting  band  and  its  resistance  overcome.  This  may 
be  facilitated  by  anesthetics  or  chloral.  The  best  reliance  is  upon 
patient  and  continuous  manual  efforts. 

How  may  the  bulk  of  the  placenta  affect  its  delivery? 

A  very  large  placenta,  which  has  fallen  centrally  upon  the  os,  in- 
stead of  edgewise,  may  be  too  bulky  to  pass  without  assistance.     The 


MISCELLANEOUS   COMPLICATIONS  1 73 

same  may  occur  with  a  placenta  of  moderate  size,  if  clots  have 
formed  behind  it  to  such  an  extent  as  to  prevent  it  from  being  doubled 
up. 

How  is  such  a  placenta  to  be  delivered? 

It  should  be  perforated  centrally  by  one  or  two  fingers,  which  will 
enable  us  to  ho©k  into  and  drag  it  down. 

What  is  utero-placental  vacuum? 

A  rare  occurrence,  in  which  the  placenta  being  detached,  a  pull 
upon  the  funis  makes  a  vacuum  between  the  placenta  and  the  uterine 
wall,  converting  it  into  a  sucker,  resembling  in  action  the  leather  disc 
by  which  the  small  boy  raises  bricks  from  the  pavement. 

How  may  it  be  detected  and  remedied? 

It  resembles  at  first  the  large  placenta,  or  one  enlarged  by  clots, 
but  as  soon  as  perforated,  and  the  vacuum  destroyed,  it  is  delivered 
with  great  ease,  or  even  spontaneoulsy  expelled  at  once. 

INVERSION  OF  THE  UTERUS 

What  is  inversion  of  the  uterus? 

The  uterus  is  turned  inside  out,  upside  down  (Parvin). 

1.  There  may  be  a  simple  depression  of  the  fundus,  or  it — 

2.  May  present  at  the  os  uteri  (partial  inversion),  or — 

3.  Passes  through  the  os  and  extends  to  or  through  the  vulva  (complete 
inversion) . 

What  is  the  cause  of  inversion? 

Partial  and  irregular  contraction  of  the  uterus  is  the  main  factor; 
often  aided  by  traction  upon  the  cord  in  delivering  the  placenta. 
No  one  can  invert  a  healthy  womb  by  traction  upon  the  cord,  but 
if  the  fibers  under  the  placental  site  are  not  contracting,  inversion 
will  be  very  likely  to  occur.  It  may  happen  either  before  or  after 
the  placenta  is  detached.  Violent  efforts  at  bearing  down  have  been 
described  as  a  cause. 

How  may  inversion  be  recognized? 

I.  The  woman  usually  complains  of  great  pain  at  the  moment  of 
the  accident  (a  sensation  as  of  something  tearing  loose  within  her). 
2.  Hemorrhage  and  more  or  less  shock  follow.  3,  The  hand  placed 
upon  the  abdomen  fails  to  find  the  womb  in  its  natural  place,  but  in- 


174 


COMPEND    OF    OBSTETRICS 


stead  recognizes  a  funnel-shaped  depression  where  the  fundus  uteri 
ought  to  be.  By  vaginal  examination  the  inverted  tumor  covered 
by  endometrium  can  be  felt  and  often  seen.  Occasionally  in  complete 
inversion  the  orifices  of  the  Fallopian  tubes  can  be  seen.  It  can  then 
be  mistaken  for  nothing  but  a  fibroid  tumor,  which,  of  course,  could 
not  occupy  the  vagina  just  after  delivery. 


-\i—e 


Fig.  64. — Three  Degrees  of  Inversion. 
I.  Depression.     2.  Introversion.     3.   Complete  inversion,     a.  Fundus  uteri,     b,  6. 


Inversion    partially    filling    the    uterine    cavity, 
inverted  portion. — From  Parvin's  Obstetrics. 


c.  Vagina,     d,  d.   Mouth    of 


What  is  the  prognosis? 

Although  a  very  grave  accident,  the  prognosis  is  not  hopeless.  It 
depends  much  on  the  amount  of  hemorrhage  and  shock.  If  remain- 
ing long  in  its  displaced  condition,  inflammation  is  apt  to  occur.  The 
more  quickly  the  organ  is  replaced,  the  more  favorable  the  prognosis. 

How  is  inversion  to  be  treated? 

1 .  The  placenta,  if  adherent,  is  to  be  detached. 

2.  The  womb  should  then  be  squeezed  within  the  hand,  to  reduce 
its  bulk,  and  attempts  made  to  replace  the  fundus,  with  the  hand 
grasping  it,  while  the  other  hand  presses  downward  in  the  hypo- 
gastric region,  making  counter-pressure. 

3.  If  this  fails,  endeavor  to  indent  the  uterine  globe  with  a  knuckle 
or  the  finger  tips,  and  thus  reinvert  it.  The  indentation  is  said 
to  be  best  ejffected  at  the  opening  of  a  Fallopian  tube.  Pressure 
should  be  firmly  and  patiently  continued,  and,  if  employed  just 
after  the  accident,  rarely  fails. 

4.  After  the  fundus  is  replaced  the  hand  should  remain  within  the 
uterus  for  some  time,  or  until  expelled. 


INVERSION    OF   THE    UTERUS  1 75 

5.  Continuous  pressure  may  be  made  by  means  of  a  colpeurynter 
and-  elastic  bands.  This  method  has  been  considerably  used  by 
German  obstetricians. 

What  is  to  be  done  in  case  of  failure? 

If  called  too  late,  or  if  replacement  cannot  be  effected  without 
violence,  the  fundus  should  be  bathed  with  somewhat  diluted  tinc- 
ture of  iodin,  to  restrain  hemorrhage,  and  allowed  to  remain  in- 
verted for  one  or  two  months,  or  until  involution  has  taken  place, 
when  the  reposition  may  be  attempted  by  the  method  of  White. 

What  is  the  emphysema  of  the  neck? 

During  the  bearing-down  efforts  of  the  second  stage,  it  some- 
times happens  that  a  few  air  vesicles  in  the  lungs  are  ruptured, 
and  air  escapes  by  way  of  the  mediastinal  space  to  the  cellular 
tissues  of  the  neck  and  face.  It  is  usually  limited  to  one  side,  the 
tissues  being  swollen  and  crackling  under  the  fingers.  It  may  cause 
great  alarm,  but  is  innocuous  if  let  alone,  subsiding  in  a  few  days  with- 
out any  ill  consequences. 

What  ill  consequences  attend  laceration  of  the  mother's  tissues? 

The  only  immediate  consequences  are  hemorrhage  or  septic  in- 
fection. 

The  remote  consequences  may  be  serious,  especially  when  the 
perineum  or  cervix  is  badly  torn. 

What  is  to  be  done  when  the  cervix  is  lacerated? 

Some  authorites  recommend  that  sutures  should  at  once  be  in- 
serted, but  in  general  practice,  if  the  tear  does  not  extend  into 
the  vaginal,  insertion,  it  is  often  better  to  let  it  alone,  and  repair  it 
at  some  time  later.  Some  obstetricians  prefer  to  do  it  immediately 
after  labor  while  others  prefer  to  leave  it  until  some  weeks  or 
months — after  the  uterus  has  undergone  involution.  In  the  latter 
instance  an  intermediate  or  secondary  operation  must  be  done.  If  the 
laceration  be  large,  it  is  best  repaired  immediately  to  prevent'  sub- 
sequent hemorrhage. 

What  method  is  used  in  the  immediate  repair  of  a  lacerated  cervix? 

The  patient,  physician  and  his  instruments  having  been  prepared, 
the  cervix  should  be  grasped  preferably  by  two  volsella  forceps 
one  pair  for  each  lip.  These  should  be  held  by  an  assistant.  A 
curved  needle  with  chromicized  catgut  is  then  passed  through  the 


176  COMPEND   OF   OBSTETRICS 

torn  edges  beginning  at  the  top  of  the  laceration.  The  sutures  should 
not  pierce  the  mucous  membrane  lining  the  cervix.  Interrupted 
sutures  are  usually  employed.  Care  should  be  taken  not  to  close  the 
cervical  canal.     All  torn  edges  should  be  neatly  approximated. 

What  is  to  be  done  when  the  perineum  is  lacerated? 

Most  authorities  recommend  that  it  should  at  once  be  united 
with  sutures,  unless  of  very  slight  extent.  If  the  laceration  is  only 
through  the  vaginal  mucous  membrane  and  musculature  it  is  an 
incomplete  tear.  If  extending  into  the  rectum  it  is  a  complete  lacera- 
tion. The  method  of  closing  an  inconiplete  tear  is  to  suture  the 
edges  of  the  laceration,  using  chromized  catgut,  begining  from  the  up- 
per end.  Interrupted  sutures  are  usually  used.  The  stitch  should 
include  all  torn  surfaces.  The  ends  of  the  sutures  are  cut  close.  The 
perineum  is  united  with  silk- worm-gut  sutures  begining  at  the  vaginal 
end  of  the  laceration  and  working  downward  toward  the  rectum. 
The  sutures  are  tied  and  the  ends  left  long.  The  suture  ends  may 
be  bunched  together  to  prevent  the  ends  sticking  the  patient.  The 
silk- worm-gut  suture  should  be  removed  in  eight  to  ten  days.  In  com- 
plete laceration  the  rectum  should  be  first  closed  by  sutures  of 
fine  but  well  chromicized  catgut,  these  should  not  pierce  the  rectal 
mucous  membrane.  All  muscle  bundles  of  the  sphincter  ani  should 
be  carefuUy  united  from  above  downward  as  in  any  other  opera- 
tion for  complete  laceration.  The  remainder  of  the  operation  is 
done  in  the  same  manner  as  in  incomplete  laceration. 

OBSTETRIC  OPERATIONS 

What  are  the  capital  operations  of  midwifery? 

I.  The  induction  of  premature  labor.  2.  The  use  of  the  forceps. 
3.  Version.  4.  Symphysiotomy.  5.  The  Csesarean  section,  or  coelio- 
hysterotomy,  and  its  modifications — notably  the  Porro  operation, 
or  coelio-hysterectomy.     6.  Embryotomy  in  various  forms. 

What  are  the  obstetric  forceps? 

Two  separate  and  similar  pieces  of  steel,  each  fashioned  into  a 
blade  and  handle,  intended  to  cross  each  other  in  the  middle  and 
be  temporarily  united  at  that  point  by  a  lock. 

What  is  the  object  of  the  forceps? 

I.  They  are  used  to  seize  the  child's  head  and  to  make  traction  upon  it. 


OBSTETRIC    OPERATIONS  1 77 

2.  They  are  used  to  aid  the  rotation  of  the  head. 

3.  They  are  used  to^ex  or  extend  the  head,  as  may  be  required. 

Why  is  a  fenestra  or  open  space  made  in  the  blades? 

To  allow  the  parietal  protuberances  to  project,  thereby  permit- 
ting the  forceps  to  be  applied  to  the  head  without  at  all  adding  to 
its  bulk. 

What  curves  exist  in  the  blades? 

1.  The  pelvic  curve,  so  that  they  can  be  applied  at  any  point  in 
the  pelvic  canal  with  equal  ease. 

2.  The  head  (or  capital)  curve,  by  which  they  are  bowed  outwardly, 
so  as  to  enable  them  to  grasp  and  hold  the  head. 

How  many  forms  of  lock  are  in  common  use? 

The  mortise,  or  English  lock;  the  pivot,  or  French  lock;  and  the 
button,  or  German  lock. 

How  are  the  blades  distinguished  and  named? 

The  blade  to  the  left  is  called  the  left  blade,  or,  when  provided  with 
the  pivot  or  button,  is  sometimes  called  the  male  blade. 

The  blade  to  the  right  is  called  the  right  blade,  or,  when  provided 
with  a  slot,  it  sometimes  called  the  female  blade. 

When  should  the  forceps  be  applied? 

In  any  case  where  the  head  presents,  and  where  prompt  delivery  is 
necessary  (either  for  mother  or  child),  or  to  be  regarded  as  prefer- 
able to  waiting  upon  the  natural  efforts,  providing  the  presenting 
head  and  maternal  pelvis  are  of  relative  size. 

May  they  be  applied  during  the  first  stage? 

There  are  few  circumstances  which  warrant  us  in  applying  them 
before  full  dilatation  of  the  os  and  engagement  of  the  head.  The 
necessity  for  prompt  delivery  should  be  very  clear,  since  bruising 
and  laceration  of  the  pelvic  and  cervical  tissues  are  almost  inevitable. 

What  preliminaries  are  requisite  to  their  application? 

The  consent  of  the  woman  being  obtained,  she  should  be  given  an 
anesthetic.  The  bladder  should  be  emptied  by  catheter  after  she  is 
under  the  anesthetic.  The  bowels  should  be  evacuated  by  an  enema. 
All  the  external  genitals  should  be  well  cleansed  by  soap  and  water 
and  a  suitable  antiseptic.  The  vulvar  hair  should  be  shaved  off.  If 
much  handling  has  previously  been  done  the  patient  should  have  a  co- 


178 


COMPEND    OF    OBSTETRICS 


pious  vaginal  douche  of  lysol  2  per  cent,  or  salt  solution.  She  should  be 
placed  upon  her  back  at  the  edge  of  the  bed,  her  thighs  flexed  on  the 
abdomen,  and  her  feet  supported  on  chairs  or  preferably  by  an  as- 
sistant. The  forceps  should  be  well  boiled  in  a  sterilizer  before 
using. 

What  station  should  the  physician  occupy? 

Seated  upon  a  chair,  directly  in  front  of  the  vulva,  the  forceps 
placed  within  reach. 

How  should  the  forceps  be  applied  to  the  L.  O.  A.  position  at  the 
inlet? 

1.  The  physician  should  take  the  left  blade. in  his  left  hand,  holding 
the  handle  securely,  and,  having  anointed  both  the  blade  and  the 
the  right  hand  with  sterile  vaselin,  pass  the  blade  into  the  vagina 
on  the  woman's  left  side  high  enough  to  enable  him  to  feel  the 
rim  of  the  os  uteri. 

2.  Pass  the  blade  along  the  palmar  surface  of  the  right  hand  or 
fingers,  aiming  to  place  the  blade  under  the  left  sacro-iliac  arch, 
and,  therefore,  along  the  left  side  of  the  child's  head.  This  is 
usually  very  easy,  as  there  is  a  free  space  at  that  point.  Care 
should  be  taken  to  pass  it  between  the  cervix  and  head. 


Fig.  65. — Davis  Forceps — Upper  View. 


3.  When  the  first  blade  has  been  adjusted  to  the  head,  its  handle 
should  be  pressed  well  against  the  perineum,  so  as  to  keep  it  out 
of  the  way. 

4.  The  right  hand  is  now  cleansed  and  takes  up  the  right  blade, 
which,  with  the  left  hand,  is  anointed,  and  the  fingers  of  the 
latter  passed  into  the  vagina,  to  guard  the  rim  of  the  os  uteri, 

5.  The  right  blade  is  then  introduced  upon  the  palmar  aspect  of 
the  fingers  of  the  left  hand,  with  the  view  of  insinuating  it  be- 
tween the  child's  head  and  the  cervix,  and,  therefore,  upon  the 
right  side  of  the  head. 

6.  When  the  second  blade  is  fully  introduced,   the  shank  of  the 


OBSTETRIC    OPERATIONS 


179 


forceps  should  lie  upon  that  of  the  first  blade,  with  the  slot  just 
opposite  the  pivot,  and,  the  handles  being  now  compressed,  the 
instrument  is  locked  and  fully  applied. 

How  should  the  first  blade  be  held  at  the  beginning  of  introduction? 

As  the  tip  of  the  blade  enters  the  vulva,  the  handle  should  be  held 
nearly  perpendicular,  with  the  tip  above  the  inner  limit  of  the  right 
groin.  The  rest  of  the  introduction  resembles  the  passage  of  the 
catheter  in  the  male. 


Fig.  66. — Showing  the  Manner  of  Inserting  the  Blades  of  the  Forceps. 


How  should  the  second  blade  be  held  at  the  ^beginning  of  its 
introduction? 

As  the  tip  of  the  blade  enters  the  vulva,  the  handle  should  lie 
in  the  line  of  and  almost  touching  the  left  groin.  The  handle  is 
then  brought  almost  directly  to  the  median  line,  and  the  blade 
pushed  onward  and  upward,  as  soon  as  the  handle  is  free  from  the 
left  leg. 

What  should  be  done  if  the  instrument  cannot  be  locked? 

The  second  blade  should  be  withdrawn  and  more  carefully  reap- 


i8o 


COMPEND   OF   OBSTETRICS 


plied.     Locking  can  often  be  effected  by  simply  pushing  the  handles 
well  back  upon  the  perineum. 

How  should  the  forceps  be  held  in  making  traction? 

The  handles  should  be  grasped  with  the  right  hand  and  gently 
compressed;  the  left  hand  should  be  placed  over  the  lock,  with  a 
finger  upon  the  top  of  each  blade. 

How  is  traction  to  be  made? 

I.  The  left  hand  presses  or  pushes  the  blades  downward  and  back- 
ward (and  slightly  to  the  right),  while  the  right  hand  pulls  the 


Fig.  67. — Showing  Manner  of  Making  Traction  in  a  Low  Application  of  the 

Forceps. 

In  the  above  cut,  the  left  hand  instead  of  the  right  is  shown  grasping  the  forceps, 
.  while  the  right  hand  protects  the  perineum. 


handles  partly  in  the  reverse  direction  and  partly  in  the  line  of  the 
handles. 
2.  As  the  head  descends,  the  direction  of  traction  is  changed,  being 
made  in  the  curve  of  the  obstetric  canal  at  all  times. 

How  long  should  traction  be  made? 

For  about  a  minute  at  a  time,  with  an  interval  of  the  same  or 
greater  length,  during  which  the  handles  should  be  partly  unlocked, 
to  remove  the  compression  of  the  forceps  from  the  child's  head. 


OBSTETRIC   OPERATIONS  l8l 

Should  traction  be  made  during  a  labor  pain? 

The  contractions  may  be  disregarded  until  the  head  presses  upon 
the  perineum,  when  traction  should  be  made  only  in  the  absence  of 
uterine  contractions,  and  if  the  operator  is  not  sure  of  his  skill  he 
should  withdraw  the  forceps  at  this  point. 

How  may  the  forceps  be  withdrawn? 

By  reversing  the  motion  used  in  applying  them,  and  with  the 
same  deliberate  ease. 

How  are  the  forceps  applied  at  the  inferior  strait? 

The  head  having  rotated,  the  blades  will  be  on  opposite  sides 
of  the  pelvis,  when  on  the  sides  of  the  head.  Therefore,  both  blades 
are  passed  in  the  same  manner,  and  nearly  as  the  first  blade  is  passed 
in  the  high  operation. 

How  are  the  forceps  to  be  applied  to  an  R.  O,  P.  position  at  the 
inlet? 

Precisely  as  in  the  L.  O.  A.  position. 

How  is  traction  to  be  made  in  the  R.  O.  P.  position? 

1.  The  handles  should  be  grasped  firmly,  so  as  to  hold  the  head 
securely  while — 

2.  The  handles  are  elevated,  with  scarcely  any  traction,  so  as  to 
flex  the  head;  this  being  a  necessary  part  of  the  natural  mechanism. 

3.  Traction  should  then  be  made  in  the  axis  of  the  canal,  and  with 
as  little  compression  as  possible,  in  order  not  to  interfere  with 
rotation. 

4.  If  the  twisting  of  the  handles  shows  a  tendency  to  rotate,  this 
may  be  aided;  but  rotation  should  not  be  forced. 

How  are  the  forceps  to  be  applied  in  the  R.  O.  A.  and  L.  O.  P. 
positions? 

The  position  of  the  head  being  the  reverse  of  the  L.  O.  A.  and 
R.  O.  P.  positions,  the  right  side  of  the  head  is  behind  and  at  a 
distance,  the  left  side  in  front,  and  near.  Therefore,  the  right  blade 
is  first  applied,  under  the  right  sacro-iliac  arch,  and  in  the  same  way 
as  the  first  blade  in  the  other  position.  The  left  blade  is  then  in- 
troduced in  a  manner  corresponding  to  the  second  blade,  in  the 
L.  O.  A. 

What  difficulty  is  then  encountered? 

The  shank  of  the  left  blade  will  lie  over  the  right  blade,  and  the 
instrument  cannot  be  locked. 


1 82  COMPEND    OF    OBSTETRICS 

How  is  this  to  be  remedied? 

Take  hold  of  the  handles  separate!}^,  and  bring  each  handle  to 
the  median  line  and  beyond,  until  the  handle  of  the  right  blade 
can  be  lifted  over  that  of  the  left  blade.  They  will  then  be  in  posi- 
tion for  locking. 

How  are  the  forceps  to  be  applied  on  the  face  presentation? 

In  the  first  and  third  positions,  precisely  as  in  the  vertex,  first 
and  third.  In  the  second  and  fourth  positions,  precisely  as  in  the 
vertex,  second  and  fourth. 

May  the  forceps  be  used  on  any  part  but  the  head? 

They  have  been  used  upon  the  breech,  but  are  of  doubtful  utihty 
as  compared  with  other  procedures,  and  not  free  from  danger  when 
so  applied.  The  objections  do  not,  however,  apply  to  the  axis 
traction  forceps. 

How  are  forceps  applied  in  head-last  labors? 

If  rotation  has  taken  place,  they  should  be  applied  to  the  side  of 
the  face,  beneath  the  child's  body.  When  the  chin  is  in  front,  pass 
the  forceps  under  the  child's  back  and  raise  the  handles.  In  extrac- 
tion, when  the  head  is  flexed,  the  child's  back  should  be  carried 
toward  the  mother's  back. 

How  should  the  forceps  be  applied  when  the  chin  is  posterior? 

In  this  case  they  should  be  passed  under  the  abdomen,  and  the 
handles  raised  as  before.  In  extraction,  the  body  of  the  child  is 
raised,  its  back  directed  toward  the  mother's  abdomen. 

What  are  the  dangers  of  forceps  delivery? 

Principally,  dangerous  laceration  of  the  maternal  soft  parts, 
increasing  the  danger  of  sepsis  by  presenting  a  large  absorbing  sur- 
face; increased  shock.  Considerable  injury  to  the  pelvic  bones  can 
be  done.  In  the  child  harm  may  result  from  pressure  on  the  skull; 
many  cases  of  impaired  mental  condition  may  be  traced  to  this 
source. 

What  are  the  indications  for  the  use  of  the  forceps? 

1.  For  delay  in  the  second  stage  of  labor,  arising  from  {a)  uterine 
inertia;  {h)  any  obstruction  or  disproportion  of  slight  degree. 

2.  For  delay  in  the  first  stage,  rarely,  as  in   (a)  placenta  praevia; 
{h)  organic  rigidity;  (c)  absence  of  natural  dilating  agents. 

3.  For  rapid  delivery,  when  required,  by  such  complications  as  (a) 


OBSTETRIC    OPERATIONS 


183 


convulsions;  (b)  prolapse  of  the  funis;  (c)  excessive  uterine  action 
menacing  rupture. 
4.  For   secondary   purposes,    as   for    (a)   extraction   of   the   child   in 
the  vaginal  Cesarean  section;  (b)  after  rupture  of  the  uterus;  (c) 
for  removal  of  tumors  or  foreign  bodies  from  the  maternal  passages. 

What  is  the  principal  circumstance  demanding  their  use? 

Uterine   inertia,    or   insufficiency    of   the   uterine    contractions   to 
complete  the  labor. 


Fig.  68. — Simpson's  Forceps  with  Poulet  Tapes  and  Axis-traction  Handles. 


How  long  should  the  second  stage  be  allowed  to  continue  before 
resorting  to  the  forceps? 

Rarely  over  one  or  two  hours.  It  is  irrational  to  subject  the 
woman  to  long-continued  pain  and  effort  when  we  can  harmlessly 
deliver  by  art. 

What  alternatives  do  we  possess  to  the  use  of  the  forceps? 

If  the  child  is  living,  the  mother  in  good  condition  and  in  a  hospital, 
delivery  by  vaginal  Cesarean  section  may  be  done  if  no  great  pelvic 
deformity  exists  or  delivery  by  abdominal  Cesarean  section,  may  be 
preferred. 

If  the  patient  is  in  a  house  and  cannot  be  in  a  hospital  for  any 


184  COMPEND    OF   OBSTETRICS 

reason  or  when  the  attendant  does  not  possess  the  necessary  surgical 
training  to  do  these  operations,  he  may  resort  to : 
Version  and  embryotomy — 

1.  If  prompt  deHvery  is  indicated  in  any  case,  we  may  employ 
version. 

2.  If  the  forceps  fail  to  extract  the  child,  or  the  pelvis  is  so  deformed 
as  to  render  their  use  impracticable,  we  may  perform  version  (ac- 
cording  to  some  authorities)  or  resort  to  embryotomy. 

3.  The  last  generation  of  ph^^sicians  used  a  substitute,  the  vectis, 
which  is  simply  a  single  blade  of  the  forceps.  It  was. used  to  slip 
over  the  head  to  flex  it,  or  by  alternately  pressing  on  one  side  and 
the  other  to  make  traction.  It  can  do  nothing  which  cannot  be 
better   done  by  the  forceps. 

What  is  axis  traction? 

When  the  forceps  are  applied  to  the  head  high  up,  at  the  pelvic, 
brim,. or  above  the  pelvic  floor,  it  will  be  found  that  traction  made  in 
the  usual  way  will  have  no  effect,  but  must  be  made  in  another  direc- 
tion, i.e.,  in  the  axis  of  the  birth  canal;  that  is,  downward  and  back- 
ward, upward  and  forward,  as  the  woman  lies  in  bed. 

What  is  necessary  to  make  this  form  of  traction? 

A  pulling  power  must  be  applied  to  the  blades  in  such  a  way  that 
traction  can  be  made  on  them  directly  in  a  downward  and  back- 
ward direction;  this  is  nearly  at  right  angles  with  that  exercised 
normally  by  th^  handles,  which  is  upward  and  forward. 

When  and  for  what  uses  do  we  apply  axis  traction? 

In  cases  when  the  woman's  strength  fails,  the  child  is  large,  or  a 
slight  degree  of  pelvic  contraction  exists,  when  the  head  is  above  the 
pelvic  brim,  or  within  the  brim  and  above  the  pelvic  floor,  before 
rotation  has  occurred,  axis  traction,  properly  applied,  aids  rotation 
and  tends  to  flex  the  head. 

How  should  the  blades  be  applied? 

In  the  same  manner  as  the  low  application,  except  that  the  blades 
are  applied  in  the  oblique  diameters  of  the  pelvis  if  rotation  has  not 
occurred  so  as  to  grasp  the  side  of  the  fetal  head.  The  forceps  and 
head  may  be  allowed  to  rotate  together,  traction  being  made  only  by 
means  of  the  traction  bar  or  tapes,  the  handles  being  simply  raised. 
As  soon  as  the  pelvic  floor  is  reached,  the  traction  can  be  made  up- 


VERSION  185 

ward  and  forward  with  the  handles.     No  traction  must  be  made  by 
the  handles  before  this  time. 

VERSION 

What  is  version? 

The  operation  by  which  the  presentation  of  the  child  is  changed; 
called,  also,  turning. 

How  many  kinds  of  version  are  there? 

1.  As  regards  the  choice  of  presentation  there  are  two — • 

(a)  cephalic,  in  which  the  head  is  made  to  present;  and 
{h)  podalic,  in  which  the  breech  is  made  to  present. 

2.  As  regards  the  mode  by  which  it  is  effected,  we  have  three — - 

{a)  internal,  in  which  the  hand  is  passed  into  the  womb  to 

effect  the  change; 
{b)  external,  in  which  the  change  is  effected  by  manipulation 

through  the  abdominal  walls  only;  and 
(c)  bipolar,  or  combined,  in  which  one  hand  upon  the  abdomen 
and  two  fingers  (or  more)  internally  are  used. 

What  are  the  indications  for  version? 

1.  To  convert  a  transverse  presentation  into  one  of  the  vertex  or 
breech. 

2.  When  rapid  delivery  is  required,  and  the  use  of  the  forceps  is  not 
feasible,  podalic  version  is  indicated. 

3.  According  to  some  authorities,  to  render  delivery  easier  in  deformed 
pelves.  Internal  version  is  always  done  to  turn  the  child  with 
the  breech  at  the  inlet.  It  is  always  therefore  podalic.  External 
version  may  be  cephalic  or  podalic,  usually  the  former.  Bipolar 
version  may  be  either  cephalic  or  podalic. 

What  are  the  indications  for  internal  version? 

It  is  preferred  in  delivery  of  the  second  of  twins,  in  central  or 
partial  placenta  prasvia  and  when  for  any  reason  a  quick  delivery 
is  necessary.  The  os  must  be  sufficiently  dilated  to  admit  the 
hand;  the  patient  should  be  under  an  anesthetic  with  bowels  and 
bladder  well  emptied.     The  membranes  must  be  ruptured. 

How  is  internal  version  performed? 

I.  The  patient  lying  on  her  back  with  hips  at  the  edge  of  the  bed, 
the  hand  is  cautiously  passed  into  the  uterus  until  a  foot  is  reached 
and  seized.     As  this  foot  is  pulled  down,  the  child  is  turned  until  the 


1 86  COMPEND    OF    OBSTETRICS 

breech  presents.  While  this  is  being  done,  the  other  hand  makes 
counter-pressure  externally  upon  the  fundus.  According  to  some, 
version  will  be  easier  if  we  seize  the  foot  which  is  furthest  from  us. 

What  cautions  are  necessary? 

1.  To  introduce  the  hand  slowly  and  gently,  lest  the  womb  be 
lacerated.  Anesthesia  is  generally  of  service  in  promoting  uterine 
relaxation. 

2.  Not  to  mistake  a  hand  for  a  foot. 

What  posture  assists  in  version? 

When  a  transverse  presentation  is  impacted,  the  woman  may  be 
placed  in  the  knee-chest  posture,  which  will  aid  in  introducing  the 
hand. 

What  are  the  indications  for  external  version? 

When  the  child  is  presenting  either  transversely  or  with  the  head 
in  one  or  other  iliac  fossa.  It  is  usually  done  before  labor  or  at  the 
beginning  of  it  before  the  membranes  have  been  ruptured. 

How  is  external  version  performed? 

1.  By  careful  palpation  we  ascertain  the  exact  position  of  the  head 
and  breech. 

2.  One  hand  placed  over  the  head  (on  the  abdomen)  and  the  other 
over  the  breech,  push  the  head  and  breech  in  opposite  directions 
until  one  or  the  other  is  brought  into  the  pelvic  inlet.  This  is 
rarely  practicable  after  the  liquor  amnii  is  evacuated. 

What  are  the  indications  for  bipolar  version? 

Substitution  of  one  or  the  other  pole  of  the  fetus  in  a  transverse 
presentation,  central  or  partial  placenta  prasv^a,  some  cases  of  occi- 
pito-posterior  position  and  occasionally  prolapse  of  the  umbilical 
cord.  The  membranes  may  or  may  not  be  ruptured.  The  os  should 
be  partially  dilated. 

How  is  bipolar  version  effected? 

1.  One  hand  is  introduced  into  the  vagina,  and  two  fingers  made 
to  press  against  the  presenting  part. 

2.  The  other  hand  is  applied  on  the  abdomen  and  pressed  against 
the  head  or  breech  of  the  child,  while  the  fingers  of  the  other 
hand  press  the  presenting  part  upward  and  to  one  side  or  the 
other.     The  hand  introduced  into  the  vagina  should  be  the  same 


VERSION 


187 


in  name  as  the  side  of  the  pelvis  toward  which  the  fetal  feet  are 
directed.  As  soon  as  the  presenting  part  is  brought  down,  the 
membranes  should  be  ruptured  while  a  uterine  contraction  is  in 
progress.     The    strictest    asepsis    must    be    used.     This    is    also 


Fig.  69. — Bipolar  or  Combined  Method  of  Podalic  Version — First  Stage, — 

{Edgar.) 

known  as   Braxton   Hicks'  bipolar  method.     This  method  should 
always  be  tried  before  internal  version  is  resorted  to. 

Under  what  circumstances  is  version  easy  or  difficult? 

I.  When  there  is  much  liquor  amnii,  and  the  uterus  is  uncontracted, 
it  is  easy  of  performance, 

13 


i88 


COMPEND    OF    OBSTETRICS 


2.  When  the  Hquor  amnii  has  drained  away  for  some  hours,  when 
the  womb  is  tonically  or  tetanically  contracted,  and  when  the 
child  has  been  dead  long  enough  for  post-mortem  rigidity  to 
supervene,  it  is  difficult  and  sometimes  impossible. 

What  other  methods  have  we  besides  version  of  delivering  a  child 
in  transverse  position? 

If  the  mother  is  in  good  condition,  the  child  living  and  strong  and 
the  patient  is  in  a  position  to  have  hospital  facilities  the  delivery  can 


Fig.  70. — Combined   Method   of   Podalic  Version — Second   Stage. — {Edgar.) 

frequently  be  quickly  accompHshed  and  with  less  danger  to  mother 
and  child  by  delivering  by  abdominal  section. 


When  version  fails  in  a  transverse  presentation,  what  alternative 
operation  have  we? 

Embryotomy. 


EMBRYOTOMY  1 89 

EMBRYOTOMY 

What  is  embryotomy? 

The  operation  by  which  the  size  of  the  child  is  reduced  by  cut- 
ting and  mutilation.  It  is  now  restricted  to  mutilation  of  the  body; 
when  applied  to  the  head  it  is  called  craniotomy. 

What  are  the  steps  in  performing  embryotomy  on  the  transverse 
presentations? 

The  patient  having  been  put  under  an  anesthetic,  and  a  vaginal 
douche  of  i :  5000  solution  of  bichlorid  of  mercury  or  other  efficient 
antiseptic — 

1.  An  assistant  places  his  hands  on  the  abdomen  and  presses  the 
child  downward,  so  as  to  steady  it. 

2.  A  perforator  is  introduced  into  the  vagina,  and  made  to  per- 
forate the  chest,  and  to  divide  several  ribs.  Care  should  be  taken 
to  guard  the  sharp  edges  of  the  perforator  with  two  fingers,  while 
introducing  and  using  it. 

3.  A  blunt  hook,  crotchet,  or  other  instrument  is  introduced  into 
the  chest  through  the  perforation,  and  the  viscera  broken  up 
and  removed  piecemeal.     This  is  called  evisceration. 

4.  The  body  may  then  be  doubled  up  and  drawn  down  by  a  blunt 
hook  or  embryotomy  forceps. 

5.  In  a  few  cases  it  is  necessary  to  decapitate  the  child  before  it 
can  be  extracted.  This  may  be  done  by  instruments  invented 
for  the  .purpose,  or  by  improvised  methods,  if  the  operator  is 
ingenious.  ^ 

What  is  craniotomy? 

The  operation  by  which  the  head  is  lessened  in  size. 

1.  The  head  is  pressed  down  and  steadied  by  an  assistant. 

2.  The  head  is  perforated. 

3.  The  brain  is  broken  up  completely,  and,  if  necessary,  removed 
by  syringing  out  the  cranial  cavity. 

4.  Traction  is  made  upon  the  head  by  a  finger  hooked  into  the  per- 
foration, by  craniotomy  forceps,  or  by  any  suitable  instrument, 
and  the  head  collapses  and  is  drawn  out.  If  not  sufficiently  reduced 
in  size  by  these  steps,  we  proceed  to  cranioclasm. 

What  is  cranioclasm? 

The  operation  by  which  the  vault  of  the  cranium  is  removed. 


igo 


COMPEND   OP   OBSTETRICS 


Craniotomy  is  performed  as  above. 

2.  With  the  cranioclast  (or  crani- 
otomy forceps)  seize  an  edge  of 
bone  at  the  perforation,  and 
wrench  off  as  large  a  piece  as 
possible,  which  is  then  cautiously 
withdrawn.  This  is  repeated  until 
the  vault  of  the  cranium  is  removed. 

3.  The  head  is  then  tilted,  so  that 
the  craniotomy  forceps  can  seize 
the  face,  and  the  thin  base  of 
the  skull  is  drawn  down  through 
the  pelvis. 

What  cautions  are  necessary? 

1.  To  preserve  the  scalp,  so  that 
the  sharp  edges  of  bone  may  be 
covered  while  it  is  withdrawn. 
Therefore,  the  scalp  is  to  be 
dissected  up  before  using  the 
cranioclast,  and  its  blades  placed 
one  inside  the  skull,  and  the 
other  between  and  scalp  and 
outside  of  the  skull. 

2.  To  guard  the  edges  of  frag- 
ments of  bone  with  two  fingers 
while  withdrawing  them. 

3.  To  preserve  the  most  strict  aseptic 
cleanliness. 

If  even  the  base  of  the  skull  is  too 
large  to  pass,  what  alternative  have 
we? 

Cephalotripsy,  in  which  a  powerful 
pair  of  forceps  (the  cephalotribe)  is 
applied,  and  made  to  crush  the  base. 
Cephalotripsy  may  also  be  used  be- 
fore    resorting    to    cranioclasm,    but 

perforation  of  the  cranium  should  always  precede  the  application  of 

the  cephalotribe. 


Fig.  71. — Simpson's   Cranioclast. 


CESAREAN   SECTION 


191 


CESAREAN  SECTION 

What  is  the  Cesarean  section? 

Coelio-hysterotomy,  or  the  removal  of  the  child  through  an  in- 
cision made  in  the  abdominal  walls  and  uterus.  The  term  is  some- 
times incorrectly  applied  to  simple  gastrotomy  (laparotomy)  after 
rupture  of  the  uterus. 

"What  are  the  indications  for  the  Cesarean  section? 

I.  A  pelvis  contracted  to  2  inches  in  the  conjugate,  or  obstructed 
by  tumors,  or  other  insurmountable  obstacles  to  delivery  by  the 
natural  way.  The  indications  for  the  operation  are  frequently 
extended  to  include  cases  of  faulty  presentation,  central  or  partial 


Fig.  72. — Hicks'  Cephalotribe. 

placenta  prsevia,  transverse  position  and  eclampsia  providing 
hospital  -facilities  are  at  hand,  the  mother  is  in  good  condition  free 
from  possibilities  of  infection  and  the  child  living  and  strong. 
2.  For  the  rapid  delivery  of  a  supposed  living  child  after  the  death 
of  the  mother.  Children  have  been  saved  when  the  mother  had 
been  dead  for  more  than  an  hour. 

What  are  the  steps  in  the  Cesarean  section? 

I .  Previous  to  the  operation  the  patient  must  have  a  full  bath,  fol- 
lowed  by  a  thorough  scrubbing  of  the  abdomen  with   hot  water 


192 


COMPEND    OF    OBSTETRICS 


and  soap,  rinsing  with  hot  water  and  scrubbing  with  i  :  1000 
bichlorid  of  mercury.  An  antiseptic  dressing  should  be  appHed 
over  the  lower  part  of  abdomen;  the  bowels  and  bladder  are  to 
be  thoroughly  emptied.  Immediately  before  the  operation  the 
abdomen  must  be  prepared  as  follows : 

(a)  Wash  the  field  of  operation  thoroughly  with  soap  and  water, 

(b)  With  alcohol  or  ether. 


Fig.  73. — Vaginal  Cesarean  Section. 

Shows  initial  incision.  Transverse  incision  one  and  a  half  inches  through  mucous 
membrane  at  utero-vaginal  junction  and  vertical  incision  extending  from  the 
middle  point  of  the  transverse  incision  longitudinally  downward  through  mucous 
membrane  of  anterior  vaginal  wall  to  a  point  immediately  below  the  urethra,  thus 
making  a  "T"  incision. — (Edgar.) 

(c)  With  a  solution  of  1:1000  bichlorid  of  mercury. 

The  hands  and  arms  of  the  operator  prepared  in  the  same  manner, 
the  finger  nails  being  carefully  brushed  and  cleaned. 
2.  The  operator  stands  by  the  patient's  side,  with  his  face  toward 

her  feet,   and    begins  to  make  his  incision    near  the  symphysis. 

(To  avoid  cutting  early  into  the  placental  site.) 


CESAREAN   SECTION 


193 


3.  An  incision  is  made,  layer  by  layer,  in  the  linea  alba,  from  near 
the  pabes  to  the  umbilicus,  and,  if  necessary,  continued  further 
up  and  to  the  left  of  the  navel. 

4.  The  womb  is  cautiously  incised,  either  in  situ  or  by  bringing  it 
out  of  the  abdomen.  In  the  former  case  an  assistant  should 
keep  the  abdominal  walls  in  close  contact  with  its  surface;  in 
the  latter  it  should  be  enveloped  with  a  warm  aseptic  towel, 
and  be  held  nearly  at  right  angles  to  the  abdomen.     (Lusk.) 


/ 


Fig.  74. — Vaginal  Cesarean  Section. 

The  flaps  of  the   incision  are  turned  back  with  the   finger  or  blunt  dissector  and 
the  bladder  is  stripped  away  from  the  cervix. — {Edgar.) 


By  a  rubber  tube  or  by  manual  assistance,  pressure  should  be 
made  on  the  lower  segment,  to  prevent  hemorrhage. 

5.  As  soon  as  the  uterine  cavity  is  opened  the  membranes  must 
be  instantly  ruptured  and  the  child  quickly  extracted  by  grasp- 
ing it  by  the  feet  or  shoulder. 

6.  The  after-birth  is  delivered. 

7.  The  abdominal  cavity  is  to  be  thoroughly  sponged  out  and  the 


194 


COMPEND   OF   OBSTETRICS 


uterine  incision  closed  by  one  or  two  sets  of  sutures  of  wire,  silk, 
or  catgut.  Lusk  advises  a  stronger  one  of  wire,  silk,  or  catgut 
for  the  muscular  structures,  and  a  fine  one  of  silk  or  catgut  for  the 
peritoneal  borders. 

8.  The  abdominal  cavity  is  again  carefully  cleansed  of  all  blood  and 
fluids  by  warm  distilled  well-boiled  water  or  sterilized  normal 
saline  solution. 

9.  The  abdominal  incision  is  closed  by  suture. 


/^ 


FiG.  75. — Vaginal  Cesarean  Section. 

The  anterior  wall  of  cervix  and  lower  uterine  segment  are  bisected  in  the  median 
line  up  to  the  reflection  of  the  bladder,  exposing  the  amniotic  bag. — {Edgar.) 

10.  The  incision  is  dressed  as  after  any  other  abdominal  operation. 

11.  The  operation  and  subsequent  treatment  should  be  conducted 
with  strict  antiseptic  precautions. 

What  instruments  are  required  for  an  abdominal  Cesarean  section? 

Two  scalpels,  curved  needles  and  a  needle  holder,  suture  material, 
half  a  dozen  hemostatic  forceps,  a  pair  of  blunt-pointed  scissors, 
a  large  fountain  syringe  or  glass  irrigator,  bichlorid  or  plain  sterile 


CESAREAN    SECTION  1 95 

gauze  for  gauze  sponges,  or  natural  sponge  carefully  made  aseptic, 
plenty  of  boiled  water,  and  aseptic  towels. 

What  is  vaginal  Cesarean  section? 

It  is  a  deep  incision  of  the  anterior  cervical  wall  extending  beyond 
the  internal  os  and  into  the  lower  uterine  segment  followed  by  the 
delivery  of  the  fetus  through  this  opening  by  forceps  or  version 
(Edgar). 


/ 


Fig.  76. — Vaginal  Cesarean  Section. 
The  incisions  in  the  cervix  and  lower   uterine   segment    are  closed  with  catgut 
after  emptying  of  the   uterus,   and   the  vaginal  incisions  are  brought  together 
over  these  with  catgut. — (Edgar.) 

What  are  the  indications  for  vaginal  Cesarean  section? 

1.  Eclampsia  where  rapid  delivery  is  required  especially  if  the  cervix 
cannot  be  dilated  for  ordinary  delivery. 

2.  Cardiac  diseases. 

3.  Stenosis  of  the  cervix. 

4.  Occasionally  in  placenta   praevia.     It  is   contraindicated  in  con- 
tracted pelvis. 


196  COMPEND    OF    OBSTETRICS 

How  is  vaginal  Cesarean  section  performed? 

Operation.  Instruments  required:  i  perineal  and  three  long  vagi- 
nal retractors,  4  bullet  forceps,  strong  straight  scissors,  artery- 
clamps,  needle  holder,  6  full  curved  needles,  chromic  catgut,  vaginal 
dressings.      (Description  of  this  operation  is  from  Edgar's  Obstetrics.) 

First  step.  The  perineum  is  depressed  with  a  broad  speculum,  and 
the  cervix  grasped  with  two  tenaculum  forceps,  placed  one  on  each 
side  of  the  median  line,  about  1/2  inch  apart.  The  cervix  is  drawn 
downward  and  backward  into  the  vulvar  outlet,  and  the  mucous 
membrane  at  the  uterovaginal  junction  is  incised  laterally  to  the 
extent  of  i  1/2  inch.  Some  add  a  second  incision  at  right  angles  to 
the  above  and  extending  from  the  middle  point  of  the  transverse 
incision  longitudinally  downward  through  the  mucous  membrane  of 
the  anterior  vaginal  wall,  thus  making  a  "T"  incision. 

Second  step.  The  bladder  is  now  stripped  away  by  the  finger  and 
blunt  dissection  up  to  the  point  of  deflection  of  the  peritoneum. 

Third  step.  A  long  narrow-bladed  speculum  is  now  inserted  which 
elevates  the  peritoneum  and  exposes  to  view  the  length  of  the  cervix 
and  a  portion  of  the  lower  uterine  segment. 

Fourth  step.  With  blunt-pointed  straight  scissors  the  cervix  is 
incised  anteriorly  in  the  median  line  through  the  internal  os. 

Fifth  step.  The  incision  in  the  uterus  is  now  stretched  either  with 
two  index  fingers  or  with  one  hand  inserted  into  the  vagina  after 
removing  all  instruments. 

Sixth  step.  Delivery  of  the  fetus  by  forceps  or  version,  preferably 
the  latter,  extract  the  placenta  and  membranes  manually.  Wash  out 
"uterine  cavity  with  normal  saline  solution.  Pack  with  iodoform  or 
sterile  gauze. 

Seventh  step.  Retract  perineum,  catch  cervix  with  bullet  forceps  and 
the  long  narrow  retractor  placed  to  hold  up  the  bladder  and  perit- 
oneum anteriorly.  The  incision  in  the  cervix  is  now  closed  with 
interrupted  suture  of  No.  3,  20-day  chromic  catgut  and  the  vag- 
inal incision  with  No.  2  plain  catgut.  The  external  portion  of  the 
cervical  wound  should  be  left  in  order  to  prevent  undue  contraction 
and  improper  uterine  drainage. 

What  is  Porro's  method? 

A  modification  of  the  Cesarean  section,  in  which  the  uterus  is 
removed  after  the  child  is  delivered,  and  the  stump  treated  by  leaving 
it  outside  the  peritoneal  cavity,  fixing  it  at  the  lower  end  of  the 


CESAREAN   SECTION  I97 

abdominal  incision.  Up  to  a  point  following  the  delivery  of.  the 
child  it  is  done  in  the  same  manner  as  coelio-hysterotomy.  After 
this  a  clamp  is  placed  across  the  uterus  at  the  lower  border  of  the 
lower  uterine  segment  and  the  body  amputated  above  the  clamp. 
The  clamp  holds  the  cervical  stump  in  the  lower  angle  of  the  wound. 
The  abdominal  peritoneum  is  now  closed  (leaving  room  for  drainage)  by 
sutures  of  catgut  and  is  united  to  the  peritoneum  of  the  cervical  stump. 
Gauze  is  freely  packed  around  both  stump  and  the  clamp  holding  it. 
Finally  the  stump  becomes  detached  from  the  clamp  but  is  adherent 
through  to  the  surrounding  tissues  which  hold  it  in  place. 

What  are  the  indications  for  Porro's  operation? 

The  operation  is  done  in  obstetrics  in  cases  where  there  is  a  possi- 
bility that  the  uterus  is  septic,  when  haste  is  required  or  when  a 
simple  form  of  hysterectomy  is  required,  the  pelvis  being  too  small  to 
admit  of  the  child  being  born  by  the  natural  way. 

What  is  coelio-hysterectomy? 

By  coelio-hysterectomy  is  understood  abdominal  incision  followed 
by  amputation  of  the  body  of  the  uterus. at  the  junction  of  the  lower 
uterine  segment  with  the  cervix.     (Davis.) 

What  are  the  indications  for  coelio-hysterectomy  in  obstetrics? 

When  the  pelvis  is  too  small  to  admit  of  the  child  being  born  by 
the  natural  way;  when  the  uterus  contains  fibroids;  when  the  pelvis 
is  so  small  that  it  is  unsafe  for  the  patient  to  again  become  pregnant, 
or  in  cases  of  severe  chronic  disease  where  future  childbirths  would 
endanger  the  life  of  the  patient. 

What  is  symphysiotomy? 

A  cutting,  partially  or  completely,  through  the  pubic  joint  in  order 
to  facilitate  delivery  by  increasing  the  size  of  the  pelvic  cavity. 

When  is  the  operation  indicated? 

According  to  most  authorities,  symphysiotomy  is  indicated  in 
cases  of  contracted  pelves  when  the  true  conjugate  is  as  low  as  2  3/4 
inches  to  3  1/2  inches.  Below  2  3/4  inches  the  operation  is  difficult. 
Many  operators  believe  that  forceps  and  version  should  be  tried  be- 
fore resorting  to  symphysiotomy.  The  operation  has  also  been 
used  in  cases  in  which  the  birth  has  been  hindered"l)y  tumors,  etc. 

When  is  Cesarean  section  preferable  to  symphysiotomy? 

In  cases  where  the  conjugata  vera  is  below  23/4  inches.  Garri- 
gues   recommends   that   symphysiotomy   should   be   done   in    cases 


1 98  COMPEND    OF    OBSTETRICS 

where  the  diagonal  conjugate  is  3  1/4  to  33/4  inches  (80  to  90  milli- 
meters). 

What  is  the  amount  of  space  gained  by  section  of  the  pubic  joint? 

The  amount  of  increase  is  principally  in  the  transverse  diameter, 
although  there  is  some  enlargement  of  the  obliques  and  antero- 
posterior diameters.  The  gain  in  space  is  2  millimeters  (2/25  of 
an  inch)  for  every  centimeter  (2/5  of  an  inch)  of  separation  of  the 
divided  ends  of  the  pubic  joint.  With  a  separation  of  6-7  centi- 
meters (23/4  inches),  the  increase  is  about  14  millimeters  or  1/2 
an  inch. 

How  far  can  the  pubic  joint  be  safely  separated? 

Not  more  than  23/4  inches  (Garrigues).  A  greater  separation 
than  this  endangers  the  sacro-iliac  joint. 


Fig.  77. — Galbi ATI's  Falcetta. 

How  is  the  operation  done? 

A  symphysiotomy  is  best  begun  at  the  time  of  complete  dilata- 
tion. The  patient  lying  on  her  back  with  thighs  flexed  on  abdo- 
men, and  under  the  influence  of  an  anesthetic,  the  pubic  region 
should  be  shaved,  and  washed  with  soap,  and  water,  alcohol  and 
bichlorid  of  mercury  i :  2000.  An  incision  3  or  4  inches  long  should 
be  made,  beginning  at  the  upper  end  of  the  symphysis  and  end- 
ing at  the  root  of  the  clitoris.  The  subcutaneous  tissue  should 
be  cut  through,  bleeding  being  checked  by  pads  of  iodoform  gauze, 
unless  severe,  when  the  wounded  arteries  must  be  found  and  ligated. 
A  metal  catheter  should  now  be  inserted  into  the  bladder  and  the 
urethra  drawn  strongly  to  the  right;  the  bladder  must  be  empty. 
The  symphysis  having  been  uncovered,  a  probe-pointed  bistoury, 
or,  better,  the  Galbiati  symphysiotomy  knife  (falcetta),  is  intro- 
duced, guarded  by  the  left  index  finger,  with  its  edge  against  the 
posterior  surface  of  the  symphysis.  The  joint  is  severed  by  pass- 
ing the  knife  in  a  direction  from  behind,  forward  and  upward.  Should 
the  joint  be  ossified,  a  chain  saw  will  be  found  of  use.     An  assistant 


CESAREAN   SECTION  199 

should  now  make  moderate  pressure  on  each  trochanter,  to  pre- 
vent injury  of  the  sacro-iliac  joints.  As  to  the  delivery  of  the  child, 
authors  are  divided,  many  believing  that  forceps  should  be  used  until 
the  head  reaches  the  pelvic  floor,  when  the  actual  birth  should  be  left 
to  nature.  Delivery  of  the  placenta  should  be  accomplished  as 
speedily  as  possible.  If  the  child  be  asphyxiated,  it  should  be  treated 
in  the  usual  way  (see  asphyxia).  Firm  pressure  should  now  be  made 
on  the  trochanters,  thus  bringing  the  severed  ends  of  the  joint  to- 
gether; care  should  be  taken,  while  this  is  being  done,  to  hold  the  blad- 
der and  urethra,  so  that  they  will  not  be  caught  between  the  ends  of 
bone.  Sutures  of  silver  wire,  silk,  or  silk-worm  gut  should  be  in- 
serted through  the  cartilage,  or,  as  some  recommend,  through  the  fi- 
brous tissue  in  front  of  the  bone;  one  or  two  stitches  of  silk  or  catgut 
are  enough  to  close  the  wound.  Drainage  may  or  may  not  be  used. 
After  the  operation  a  copious  vaginal  douche  of  some  antiseptic 
fluid  should  be  given,  the  field  of  operation  being  dusted  over  with 
iodoform  powder  and  covered  with'  an  aseptic  dressing.  A  firm 
bandage  should  be  placed  around  the  hips,  and  should  be  removed 
as  seldom  as  possible.  It  is  best  that  the  patient  lie  with  legs  out- 
stretched, and  on  her  back. 

What  is  the  after-treatment  of  symphysiotomy? 

The  same  as  in  any  other  obstetrical  case  in  which  an  operation 
has  been  done.  The  strictest  asepsis  must  be  maintained;  the 
bowels  should  be  opened  every  day  and  the  urine  withdrawn  every 
six  hours  by  means  of  a  catheter,  or  a  permanent  catheter  may  be 
left  in  the  bladder  and  connected  by  a  tube  with  a  vessel  under  the 
bed.  This  allows  the  bladder  to  empty  itself  without  disturbing  the 
patient.  The  bladder  may  occasionally  be  irrigated  with  a  mild 
solution  of  boracic  acid.  A  light  and  nutritious  diet  should  be 
given  her. 

What  is  the  prognosis  of  symphysiotomy? 

As  to  the  mortality  of  symphysiotomy,  authors  differ;  but  in 
summing  up  the  results  of  a  number  of  operators,  the  maternal 
death-rate  will  range  from  12  to  18  per  cent.  (Davis);  the  fetal  is 
very  small.  Symphysiotomy  is  an  operation  in  which  the  child 
has  undoubted  preference. 

What  is  ischio-pubiotomy? 

It  consists  of  severing  the  horizontal  ramus  of  the  pubes  from 


200  COMPEND    OF    OBSTETRICS 

the  symphysis.     It  is  said  to  have  been  used  with  success  in  cases 
of  obHquely  contracted  pelves. 

INDUCTION  OF  LABOR 

What  is  the  induction  of  premature  labor? 

The  operation  by  which  labor  is  brought  on  at  any  time  before 
full  term  and  after  the  period  of  viability. 

What  are  the  indications  for  its  performance? 

1.  In  deformed  pelves,  a  child  may  be  delivered  alive  if  labor  is 
induced  at  seven  or  eight  months  of  pregnancy,  which  would 
have  to  be  sacrificed  by  craniotomy,  if  allowed  to  develop  until 
full  term. 

2.  If  the  mother's  life  is  endangered  by  vomiting,  convulsions,  or 
other  causes,  the  operation  is  sometimes  performed. 

How  is  the  operation  conducted? 

(Barnes'  method),  i.  Pass  an  elastic  bougie  6  or  7  inches  into  the 
uterus;  coil  up  the  remainder  of  the  instrument  in  the  vagina, 
to  keep  it  in  place.     Do  this  in  the  evening. 

2.  Next  morning  proceed  to  dilate  the  cervix  by  Barnes'  (or  Moles- 
worth's)  dilators,  until  it  will  admit  several  fingers.^ 

3.  Rupture  the  mem.branes  and  reapply  the  dilator. 

4.  Allow  the  natural  efforts  to  complete  delivery,  or  use  the  forceps 
or  version. 

5.  (Thomas.)  Pack  the  child  in  cotton  or  wool  as  soon  as  born, 
and  maintain  a  suitable  temperature  by  artificial  heat,  appHed  is 
various  ways. 

THE  PUERPERAL  PERIOD 

What  is  the  period  after  delivery  called? 

The  lying-in  period,  the  puerperal  state,  or  the  period  of  invo- 
lution, because  after  labor  the  uterus  undergoes  the  process  of  in- 
volution. 

What  is  involution? 

The  process  by  which  the  womb  returns  to  its  original  size  and 
condition.  The  tissues  of  the  womb  undergo  a  form  of  fatty  de- 
generation. As  the  products  of  this  change  are  partly  absorbed 
and  partly  transuded  and  discharged  from  the  body,  the  structure 


THE   PUERPERAL   PERIOD  20I 

of  the  uterus  becomes  condensed  until  it  has  become  nearly  of 
the  same  size  and  condition  as  before  pregnancy.  The  same 
change  takes  place  in  all  the  structures  (ligaments,  etc.)  enlarged  by 
pregnancy. 

How  long  a  time  is  required  for  this  process? 

By  the  tenth  day  the  womb  is  so  diminished  as  to  be  entirely 
within  the  pelvis,  and  the  fundus  is  not  to  be  felt  above  the  inlet. 
After  this,  involution  continues  at  a  slower  rate,  being  completed 
in  about  twelve  weeks. 

What  irregularities  are  met  with? 

1.  Sub-involution;  it  may  be  protracted  by  inflammation  or  other 
concurrent  disease,  and  remain  enlarged  permanently  or  for  a  long 
time. 

2.  Super-involution;  it  may  be  rapid  and  excessive,  leading  to  atrophy 
of  the  .womb,  but  this  is  very  rare. 

What  are  the  causes  of  sub -involution? 

1 .  Any  constitutional  disease  affecting  the  constituents  of  the-  blood. 

2.  Pelvic  tumors  or  previous  attack  of  metritis  or  endometritis. 

3.  Uterine  displacements. 

4.  Getting  up  too  soon  after  delivery. 

5.  Retained  secundines. 

6.  Sexual  intercourse  too  soon  after  labor. 

7.  Mild  septic  infection  (metritis)  following  labor. 

8.  Laceration  of  the  cervix,  pelvic  floor  or  perineum. 

What  are  the  symptoms  of  sub -involution? 

1.  Heaviness  in  the  pelvis. 

2.  Pain  the  back  and  down  the  thighs. 

3.  Headache. 

4.  A  slight  temperature  rise. 

5.  A  previously  serous  lochia  changes  to  bloody. 

6.  Constipation. 

The  diagnosis  is  made  from  these  symptoms  and  finding  the  uterus 
large,  flabby  and  possibly  retro-verted  or  retro-flexed.  It  is  apt  to 
be  painful  to  the  touch. 

What  is  the  treatment? 

Rest  in  bed,  correction  of  displacements  by  a  suitable  pessary. 
Not  infrequently  irrigation  of  the  vagina  with  perfectly  sterile  hot  salt 


202  COMPEND    OF    OBSTETRICS 

solution  will  do  good ;  but  if  great  care  as  to  cleanliness  is  not  used  these 
had  better  not  be  used.  Tonics  such  as  strychnin,  cinchona,  or  small 
doses  of  quinine  are  useful  and  ergot  with  or  without  the  fluid  extract 
of  hydrastis  will  aid  in  the  contraction  of  the  uterus. 

What  are  the  lochia? 

The  "flow"  is  the  discharge  from  the  uterus  and  vagina  which 
occurs  after  labor,  and,  to  some  extent,  until  the  womb  is  com- 
pletely involuted. 

What  are  its  properties? 

It  is  a  rather  thick,  albuminous  fluid,  containing  oil  globules, 
epithelial  cells,  blood  corpuscles,  and  granular  debris  from  the  uterus. 
During  the  first  day  after  labor  it  is  of  a  red  color,  from  the  presence 
of  blood  in  excess  (or  it  may  be  blood  alone  immediately  after  labor). 
This  may  continue  for  several  days,  especially  if  any  clots  have  been 
retained  in  the  uterus,  after  which  it  becomes  straw-colored,  and 
finally  clear  and  colorless.     In  health  it  has  no  odor,  or  nearly  none. 

What  is  the  nature  of  a  lochial  fluid? 

It  is  an  excrementitious  product,  and  readily  decomposes  at  the 
temperature  of  the  body  or  a  little  higher. 

What  is  the  amount  of  the  lochia? 

At  first  it  varies  from  one-half  ounce  to  several  ounces  per  diem. 
It  is  gradually  diminished,  and  after  the  tenth  day  is  usually  scarcely 
perceptible,  being  little  more  than  the  natural  secretion  of  the  parts. 
In  some  women  it  is  very  scanty,  and  ceases  after  a  few  hours  or  a 
day  or  two,  while  in  others  it  may  continue  for  weeks. 

What  is  the  normal  condition  as  to  health  after  labor? 

The  majority  of  women  feel  in  good  health,  being  only  a  little 
tired  and  sore,  and  in  a  few  days  feel  competent  to  arise  and  resume 
their  avocations. 

Should  they  be  permitted  to  do  so? 

No.  Rest  and  quiet  are  essential  to  guard  against  the  dangers 
incident  to  this  period. 

How  long  should  the  woman  be  kept  in  bed  and  at  rest? 

Until  the  womb  has  retreated  within  the  pelvis,  and  not  allow^ed 
to  work  until  involution  is  complete.  Before  this,  the  womb  is  en- 
larged and  softened,  and  is  subject  to  displacements  and  flexions. 


THE   PUERPERAL   PERIOD  203 

What  physical  peculiarities  are  noted  in  this  period? 

1.  The  pulse  becomes  slow,  falling  to  60  beats  per  minute,  or  less. 

2.  The  temperature  is  elevated  from  0.5°  to  1°  Fahr. 

3.  The  skin  is  more  active  and  perspiration  more  free. 

4.  The  urine  is  increased  in  amount,  in  specific  gravity,  and  urates. 

5.  The  bowels  are  constipated. 

6.  The  breasts  seorete  milk. 

What  general  care  should  be  given  a  patient  during  the  puerperal 
state? 

The  patient  must  be  in  bed,  and  should  remain  there  for  at  least 
ten  days.  During  the  first  forty-eight  hours  she  should  be  on  her 
back,  after  that  she  may  turn  on  her  side.  Long  continued  laying  on 
the  back  may  favor  retrodisplacements  if  uterine  involution  is  slow. 
The  patient's  temperature,  pulse  and  respiration  should  be  taken  fre- 
quently enough  to  study  the  case  and  a  record  should  be  made  of  it. 
If  the  labor  has  been  hard  and  if  the  patient  cannot  evacuate  the 
bladder  she  may  be  catheterized  every  eight  hours  for  a  few  days. 
The  greatest  care  should  be  used  as  to  the  catheter  otherwise  the 
bladder  may  become  infected.  Usually  in  tweny-four  hours  she  can 
pass  urine  herself.  Unless  there  are  some  special  indications  for 
them,  vaginal  douches  are  not  used  after  labor,  but  the  external 
genital  organs,  the  groins  and  buttocks  should  be  cleansed  by  pour- 
ing over  them  (the  patient  lying  on  bed-pan)  bichlorid  solution 
I  :  5000  or  lysol  solution  i  per  cent,  every  day  and  besides  after 
urination  a  defecation.  The  vulva  should  be  covered  by  a  suitable 
pad  of  gauze.  A  well-fitting  abdominal  binder  is  usually  employed 
and  the  breasts  are  supported  by  a  suitable  binder  pinned  from  below 
upward  and  supported  by  shoulder  straps  to  prevent  its  sagging 
toward  the  waist.  The  patient  should  be  in  a  quiet  room  and  free 
from  disturbing  influences.  The  diet  should  be  liquid  for  the  first 
twenty-four  hours.  Soft  foods  may  then  be  given  until  the  end  of 
the  sixth  day,  then  gradually  a  solid  diet  may  be  resumed.  At  the 
end  of  the  first  twenty-four  hours  the  bowels  may  be  moved  by  a 
grain  or  two  of  calomel  followed  by  a  saline  and  a  high  enema  of  2 
to  4  quarts  of  soapsuds  or  normal  salt  solution.  Afterward,  simple 
laxatives  should  be  employed,  care  being  taken  that  these  should  not 
be  such  as  to  influence  the  milk.  Rectal  enemata  are  usually  suffi- 
cient for  this  purpose  or  an  occasional  dose  of  compound  licorice 
powder.  The  nipples  should  be  washed  with  boric  acid  solution 
14 


204 


COMPEND   OF   OBSTETRICS 


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before  and  after  each  time  the  child  nurses  and  should  be  kept  covered 

by  a  small  square  of 
sterile  gauze  held  in 
place  by  a  binder 
such  as  has  been  de- 
scribed. 

If  the  patient  has 
had  a  discharge  pre- 
vious to  labor  a 
study  of  its  bacterio- 
logic  content  should 
be  in  order.  As  a 
rule,  many  of  these 
do  not  need  douch- 
ing and  frequently 
it  is  better  to  wait 
until  after  the  puer- 
peral period  when 
more  active  treat- 
ment can  be  given 
to  the  uterine  con- 
dition causing  the 
d  ischarge.  When 
douches  are  neces- 
sary to  cleanse  the 
parts  of  such  a  dis- 
charge they  should 
be  given  by  the  phy- 
sician himself.  Us- 
ually one  a  day  is 
quite  sufficient. 


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How  should  a 
puerperal  woman  be 
fed? 

During    the    first 

^        twenty-four  hours  a 

light  diet  of  broth, 

milk-toast,  milk,  or  other  easily  digested  articles.     It  is  well  to  feed 

the  patient  once  in  every  four  to  six  hours.     From  the  third  day  the 


THE   PUERPERAL   PERIOD 


205 


limit  of  diet  can  be  enlarged;  all  pastry  and  indigestible  articles, 
however,  must  be  prohibited.  During  the  period  of  lactation  her 
diet  should  be  directed  in  such  a  way  as  to  produce  as  much  milk 
as  possible,  and  at  the  same  time  nourish  the  mother. 

How  soon  after  labor  is  milk  secreted? 

To  a  slight  extent  during  pregnancy,  and  some  is  to  be  found  in  the 
breasts  just  after  labor.  But  the  secretion  is  not  fully  established 
for  from  thirty-six  to  seventy-two  hours,  beginning  suddenly  in  some 
and  gradually  in  others. 

What  is  the  nature  of  milk? 

It  is  an  emulsion  of  oil  globules  in  an  albuminous  fluid,  containing 
salts  in  solution.     When  of  good  quality  it  is  rather  thick  (a  drop 


Fig.  79. — Appearance  of  Milk  under  the  Microscope. 

Above  transverse  line  can  be  seen  the  fat  globules  of  the  milk;  below,  the  colostrum 

corpuscles. 


adhering  to  the  finger  nail  when  inverted),  of  a  bluish  tinge  and 
sweetish  taste.  The  milk  found  in  the  breasts  just  after  labor  differs 
from  the  subsequent  secretion,  in  being  richer  in  fatty  matters  and 
slightly  purgative  to  the  child.     It  is  called  colostrum. 

What  is  weid,  or  milk  fever? 

An  irritative  fever,  lasting  from  several  hours  to  one  or  two  days, 
and  occurring  in  women  in  whom  the  secretion  of  milk  is  suddenly 
established.     It  is  due  to  reflex  irritation,  from  the  sudden  develop- 


2o6  COMPEND    OF    OBSTETRICS 

ment  of  secretory  changes  in  the  breasts.  Clinically,  it  is  distin- 
guished by  a  sudden  rise  in  temperature,  preceded  by  a  slight  rigor 
and  followed  by  free  diaphoresis,  it  is  rarely  seen  but  when  it  does 
occur  must  be  distinguished  from  a  mild  sapremia. 

What  rules  should  be  observed  concerning  lactation? 

1.  During  the  first  month  the  baby  should  nurse  regularly,  every 
two  hours  during  the  day  and  once  or  twice  at  night;  during  the 
next  month  the  intervals  may  be  lengthened  to  three  hours,  and 
afterward  to  four  hours.  Observance  of  this  rule  will  save  much 
trouble. 

2.  The  nipple  should  be  clean,  drawn  out,  and  erect  when  offered  to 
the  child,  especially  at  first. 

3.  After  nursing,  the  nipple  should  be  washed  with  boric  acid  solution, 
dried,  and  anointed  with  cacao  butter  or  other  unguent. 

4.  If  the  breasts  are  large  and  pendulous,  they  should  be  supported 
by  a  bandage  whenever  the  woman  is  in  the  upright  posture. 

What  attention  does  the  urine  require  after  labor? 

Retention  is  apt  to  occur  after  long  labors,  from  temporary  par- 
alysis of  the  bladder  and  urethra,  from  pressure.  The  catheter 
should  then  be  passed,  within  twelve  hours  after  labor,  and,  if 
necessary,  once  every  eight  hours  afterward,  until  recovery.  Hot 
cloths  are  also  useful  when  the  retention  is  due  to  local  swelling  and 
spasm. 

How  should  the  catheter  be  passed  in  the  female? 

1.  Place  the  woman  on  her  back,  with  the  knees  drawn  up. 

2.  Introduce  the  finger  into  the  vagina,  passing  it  from  below  up- 
ward, over  the  perineum  and  posterior  commissure  into  the  vulva. 

3.  Partially  withdraw  the  finger,  pressing  slightly  on  the  anterior 
wall  until  its  tip  arrives  at  the  orifice  of  the  vagina. 

4.  With  the  other  hand  pass  the  catheter  along  the  finger  to  the 
'tip,  immediately  above  which  is  the  meatus. 

If  this  fails,  the  meatus  must  be  sought  for  by  the  tip  of  the  finger, 
which  is  to  be  depressed  as  soon  as  the  catheter  arrives  at  the  vestibule. 

Do  not  try  to  pass  the  catheter  by  the  sense  of  touch  alone,  if 
not  promptly  successful,  but  remove  the  bedclothes,  and  look  for 
the  meatus.  The  catheter  should  be  sterilized  by  boiling  and  the 
parts  asepticized  before  introducing. 


THE    PUERPERAL   PERIOD  207 

What  attentions  do  the  bowels  require  after  labor? 

Owing  to  the  constipation,  it  is  usually  necessary  to  give  a  pur- 
gative on  the  third  or  fourth  day  after  labor.  This  will  not  be 
needed  if  the  bowels  move  spontaneously,  and  if  there  seems  to 
be  a  slight  inclination  to  a  movement  an  enema  will  be  preferable. 

What  rectal  difficulty  is  common  at  this  time? 

Hemorrhoids.  These  should  be  carefully  replaced  if  extruded, 
after  labor;  and  during  convalescence  an  attempt  may  be  made 
to  cure  them  by  medication. 

What  diseases  are  especially  liable  to  occur  in  this  period? 

The  lying-in  woman  is  liable  to  septicemia,  peritonitis,  and  pelvic 
inflammations,  thrombosis,  phlebitis,  pyemia,  and  mastitis. 

What  is  puerperal  septicemia? 

1.  A  fever  produced  by  the  absorption  of  septic  matter  into  the 
system  (Playfair). 

2.  By  the  term  septic  infection  is  understood  the  development  in 
the  mother's  tissues  during  labor  of  poisonous  material  (a)  formed 
from  the  cellular  elements  of  her  tissues  (sapraemia)  or  (&)  from 
the  introduction  within  her  body  of  poisonous  germs  and  their 
products  from  without — direct  septic  infection  (Davis). 

3.  It  may  occur  in  a  severe  and  acute  form,  or  in  a  mild  and  sub- 
acute form. 

4.  It  is  often  associated  with  inflammations,  by  which  its  course  is 
greatly  modified. 

5.  The  various  conditions  resulting  from  the  union  of  septicemia 
and  inflammations  are  grouped  by  some  under  the  name  of  puer- 
peral fever. 

What  are  the  causes  of  sapraemia? 

It  most  frequently  occurs  as  the  result  of  a  slight  absorption  of 
the  products  of  necrotic  tissues  the  result  of  bruising  of  the  mater- 
nal soft  parts  during  a  protracted  labor. 

What  are  the  symptoms  of  the  lighter  form  of  sepsis  (sapraemia)? 

It  usually  begins  about  the  third  day,  although  it  may  make  its 
appearance  earlier.  It  is  ushered  in  by  a  chill,  not  generally  of 
a  severe  character;  this  is  followed  by  some  fever,  the  temperature 
reaching  101°  to  103°  F.  The  temperature  gradually  falls  after  a 
short  time,  its  decline  being  accompanied  by  free  perspiration  and 


2o8  COMPEND    OF    OBSTETRICS 

without  chills.     Some  pain  may  be  felt  over  the  uterus,  and  the 
lochia  may  be  lessened  or  temporarily  arrested  and  has  an  odor. 

What  is  the  treatment  of  sapraemia? 

Protracted  labors  should  be  prevented  by  prompt  delivery,  thus 
preventing  bruising  of  the  tissues.  All  laceration  of  the  soft  parts 
must  be  promptly  closed  by  sutures  and  under  strict  antiseptic 
precautions.  The  strictest  surgical  asepsis  should  be  used  on  the 
external  genital  organs,  and  the  patient's  general  health  stimulated 
by  tonics  and  good  food. 

What  are  the  causes  of  septicemia  (direct  infection)? 

1.  Puerperal  septicemia  is  beheved  to  be  due  to  a  specific  microbe, 
which  enters  the  body  through  a  traumatic  surface. 

2.  The  poison  is  contagious,  and,  under  favorable  circumstances, 
multiples  with  great  rapidity  in  the  body. 

3.  It  is  heterogenetic,  never  autogenetic,  and  may  be  conveyed  to 
the  abraded  surface  either  by — 

(a)  the  atmosphere; 

(&)  towels  or  sponges  which  have  been  used  in  other  cases  or 

to  cleanse  suppurating  wounds,  arid  have  not  been  anti- 

septicized ; 
(c)  the  doctor  or  nurse,  who  has  been  attending  patients  with 

septicemia,   suppurating  wounds,   erysipelas,   diphtheria, 

or  other  zymotic  diseases. 

4.  The  poison  can  enter  only  an  abraded  surface. 

5.  The  retention  and  decomposition  of  fragments  of  the  placenta  or 
membranes,  clots  in  the  uterus,  or  retained  lochia  will  not  produce 
the  disease,  but  will  favor  its  development  by  forming  a  suitable 
nidus  for  the  microorganisms  on  which  the  disease  depends. 

What  are  the  symptoms  and  course  of  acute  septicemia? 

I. "Slight  chilliness;  no  rigor,  unless  complicated  by  inflammation. 
Nausea  and  vomiting. 

2.  High   fever,    usually    devel- 
oped   rapidly,    and    always  I  Temperature,  103°  to  109°. P. 
lower  in  the  morning  than  at     Pulse,  120  to  150. 

night.  J 

3.  The  pain  varies  much  with  the  seat  of  the  maximum  of  inflam- 
mation; when  this  is  near  the  peritoneum,  it  is  most  intense;  in 
other  cases  it  may  vary  from  a  sHght  tenderness  in  the  hypogas- 
trium  to  scarcely  any  pain  at  all. 


THE   PUERPERAL  PERIOD  209 

4.  Suppression  of  the  lochia  or  a  fetid  discharge  in  some  cases. 

5.  Mind  usually  unimpaired,  and  the  patient  either  cheerful  or  in- 
different. 

6.  Face  anxious  and  usually  somewhat  jaundiced.  The  tongue 
is  dry,  parched,  and  heavily  coated. 

7.  The  typhoid  state  usually  precedes  a  fatal  termination,  which 
occurs  within  a  week,  unless  recovery  takes  place.  The  above 
symptoms  are  those  found  most  frequently  in  all  forms  of  sep- 
ticemia. Other  symptoms  there  may  be  peculiar  to  organs  most 
involved  or  to  the  type  of  infection,  etc. 

What  is  the  pathology  of  pueperal  septicemia  ? 

The  pathological  lesions  vary  greatly  according  to  the  nature  of  the 
infection,  the  organ  or  organs  involved,  the  bacteria  and  their  viru- 
lence. There  may  be  but  a  slight  membrane  on  a  small  laceration 
or  a  furious  and  quickly  fatal  (sepsis  foudroyonte)  form.  As  a  rule, 
the  most  virulent  and  quick  are  those  produced  by  the  streptococcus. 
Here  the  attack  may  be  so  quick  that  the  organs  first  invaded  will 
show  comparatively  little  change.  The  mildest  are  apt  to  be  those 
produced  by  the  staphylococcus  or  colon  bacillus,  these  former  tending 
frequently  to  later  localization  in  some  part  of  the  genital  tract  or  as 
abscesses  in  other  parts  of  the  body.  However,  in  a  large  proportion, 
the  invasion  occurs  through  the  uterus  and  we  have  the  characteristic 
changes  of  a  septic  endometritis  or  metritis.  There  may  be  also 
lesions  of  the  vulva  or  vagina  (vulvitis  or  vaginitis).  The  membrane 
so  frequently  found  over  septic  lacerations  may  contain  the  pus  cocci 
or,  in  some  cases  the  true  diphtheria  microorganisms  have  been  found. 
The  septic  process  may  invadd  the  tubes  producing  salpingitis, 
peritonitis  or  a  general  pyemia  or  thrombosis  of  the  pelvic  veins  or 
of  the  leg  (phlegmasia  alba  dolens). 

What  are  the  symptoms  of  chronic  septicemia? 

1.  The  patient  remains  weak,  and  has  little  appetite. 

2.  The  tongue  is  pale  and  flabby,  and  lightly  coated,  if  at  all. 

3.  Slight  fever,  of  intermittent  type,  is  present. 

4.  The  urine  is  high-colored,  and  constipation  exists. 

What  are  the  indications  for  treatment  in  acute  septicemia? 

The  treatment  must  be  divided  into  prophylactic  and  curative. 

Prophylactic  treatment. 

If  proper  attention  is  paid  to  a  pregnant  and  parturient  woman 


210  COMPEND    OF    OBSTETRICS 

there  need  be  few  cases  of  septicemia.  The  previous  antiseptic  care 
would  include  the  care  of  the  bowels  during  pregnancy  and  labor; 
antiseptic  care  of  the  patient  during  labor  particularly  in  the  sec- 
ond and  third  stages.  The  physician's  responsibility  to  his  patient 
is  his  own  cleanliness. 
Curative  treatment. 

1.  If  the  attack  begins  in  a  sutured  perineum,  the  stitches  should  be 
cut  and  the  parts  touched  with  pure  carbolic  acid  or  tincture  of 
iodine. 

2.  If  the  infection  has  started  in  the  uterus,  and  the  patient  is  seen 
early,  if  the  uterus  contains  much  debris,  it  should  be  gently 
curetted  to  remove  all  decomposed  materials.  It  should  then  be 
thoroughly  irrigated  with  a  i:  12,000  bichlorid  solution:  a  mixture 
of  creoline  orlysol,  5j  to  the  quart,  or  sterilized  normal  salt  solu- 
tion will  do  very  well.  It  should  then  be  lightly  packed  with 
gaiize,  to  aid  drainage,  or  a  suppository  of  iodoform  may  be  in- 
serted. In  many  cases  intrauterine  irrigation  of  normal  salt 
solution  without  curettage  is  much  safer. 

3.  Whisky  administered  with  a  free  hand. 

4.  Tonic  doses  of  strychnin  or.  quinin,  are  also  useful. 

5.  The  bowels  should  be  thoroughly  opened  by  calomel,  grs.  ij  to 
V,  with  soda  bicarb.,  followed  by  a  saline  or  enema. 

6.  Some  good  may  be  obtained  by  injection  into  the  blood  or  sub- 
cutaneously  of  normal  salt  solution. 

7.  Culture  should  be  taken  from  the  lochia,  the  interior  of  the  uterus 
or  in  some  cases  from  the  blood  and,  following  this  suggestion, 
autogenous  vaccines  or  antistreptococcic  serum  may  do  good  in 
some  cases. 

8.  Later  if  localization  occurs  in  any  part  of  the  pelvis  as  shown 
by  abscesses  the  abdomen  should  be  opened  and  then  drained. 

What  are  the  indications  for  treatment  in  chronic  septicemia? 

1.  To  improve  the  action  of  the  excretory  apparatus  by  such  agents 
as  calomel,  ipecac,  and  saline  laxatives. 

2.  The  salicylates  or  quinine,  in  small  doses;  the  main  dependence 
is  to  be  placed  on  alcohol. 

What  are  the  indications  for  treatment  in  inflammations,  com- 
plicated with  septicemia? 

The  septicemia  is  to  be  regarded  as  the  chief  trouble,  and  the 
inflammation  combated  as  a  secondary  matter. 


THE    PUERPERAL   PERIOD  211 

What  is  uterine  thrombosis? 

The  formation  of  clots  in  the  uterine  sinuses,  due  to  imperfect 
contraction  of  the  womb  after  deHvery. 

What  results  may  follow  from  thrombosis? 

1.  Detachment  of  fragments,  and  formation  of  emboli  in  other  struc- 
tures, as  in  thie  lungs,  brain,  etc.,  leading  to  inflammations  in  the 
obstructed  organs,  metastatic  abscesses. 

2.  Purulent  liquefaction  of  the  thrombus  and  subsequent  escape  of 
pus  into  the  circulation,  causing  pyemia. 

3.  Extension  of  the  thrombus  into  consecutive  veins,  causing  phlebitis. 

What  is  phlegmasia  alba  dolens? 

Also  called  "milk-leg,"  is  an  inflammation  of  the  cellular  tissue  of 
the  thigh  and  leg,  usually  associated  with  femoral  or  crural  phlebitis. 
Thrombosis  of  the  vein  may  precede  or  coexist,  but  is  not  always 
present. 

What  are  the  symptoms  of  "milk -leg"? 

It  begins  usually  in  the  second  week  with — 

1.  Irregular  chilliness  and  malaise  for  several  days. 

2.  Pain,  of  a  dragging  character,  in  the  leg  and  abdomen. 

3.  A  distinct  rigor,  and  swelling  of  the  leg. 

4.  Fever  of  a  remittent  type,  changing  to  intermittent  as  recovery 
advances,  or  becoming  continuous  in  grave  cases. 

What  peculiarities  attend  the  swelling? 

1.  The  skin  is  white  and  tense. 

2.  A  red  streak  marks  the  line  of  the  vein  when  phlebitis  is  present. 

3.  Later,  the  vein  feels  like  a  hard  cord  when  palpated. 

What  are  the  results  of  "milk -leg"? 

1.  It  may  end  in  complete  resolution. 

2.  An  abscess  is  formed  along  the  vein,  and  discharges. 

3.  Gangrene  and  septicemia  may  be  developed. 

4.  If  thrombosis  is  present,  emboli  and  pyemia  may  occur. 

In  all  cases  recovery  is  slow,  and  the  leg  is  apt  to  remain  weak 
and  become  edematous,  from  permanent  obstruction  of  the  vein. 

What  is  the  treatment  in  "milk -leg"? 

1.  To  control  inflammation. 

2.  To  relieve  pain. 

3.  To  support  the  patient's  strength. 


212  COMPEND   OF   OBSTETRICS 

The  first  can  be  best  effected  by  the  use  of  atropia,  in  a  i  per 
cent,  solution,  appHed  to  the  parts  with  a  cloth,  or  by  belladonna 
ointment.  Warm  fomentations  are  useful,  or  a  lotion  of  lead  water 
and  laudanum,  or  witch-hazel,  applied  warm,  is  also  serviceable  in 
relieving  pain.  Anodynes  may  be  given  as  needed.  Absolute  rest  is 
essential.  If  an  abscess  forms  it  may  be  evacuated,  and  applications 
of  tinct.  iodini  are  useful  in  promoting  resolution. 

What  is  mastitis? 

Inflammation  of  the  breast.  It  is  divided  into:  (i)  Glandular; 
(2)  interstitial;  and  (3)  sub -glandular.  In  the  first  the  lobules  of 
the  gland  are  inflamed.  In  the  second  the  connective  tissue  is 
affected.  In  the  third  the  connective  tissue  beneath  the  gland  is 
involved. 

What  are  the  symptoms  of  mastitis? 

1.  In  interstitial  and  sub-glandular  mastitis,  the  symptoms  are 
those  of  abscess  in  the  cellular  tissue  anywhere;  slight  consti- 
tutional disturbance,  except  in  large  sub-glandular  abscess,  and 
the  pain  is  not  increased  by  suckling  the  child. 

2.  In  glandular  mastitis  there  is  a  rigor  and  high  fever,  preceded 
by  a  hard  lump  in  the  breast,  and  suckling  causes  severe  pain. 

What  is  the  treatment  of  mastitis? 

1.  When  the  connective  tissue  is  involved  suppuration  is  almost 
inevitable,  and  is  to  be  treated  on  general  surgical  principles, 
poultices,  early  incision,  and  antiseptic  treatment  being  usually 
indicated. 

2.  In  glandular  mastitis  various  measures  have  been  employed; 
massage  or  stroking,  rubbing,  and  kneading  the  breast;  endeav- 
oring to  empty  engorged  milk  sinuses,  and  to  remedy  the  blood 
stasis.  An  ice-bag  is  strongly  recommended;  also,  compression 
by  strapping  with  adhesive  plaster,  or  with  a  plaster-of-Paris 
dressing.  To  directly  affect  the  blood-supply  and  functional 
activity  of  the  gland,  belladonna  is  used,  internally  and  exter- 
nally. The  sulphid  of  calcium  internally,  and  iodid  of  lead 
or  lead  water  and  laudanum  externally  are  used,  and  many  other 
remedies  have  advocates. 

In  aU  cases  the  breast  should  be  suspended  in  a  sling.  When 
incisions  are  necessary,  they  should  be  made  in  a  line  radiating 
from  the  nipple,  to  avoid  severing  milk  ducts.     The  abscess  cavity 


THE   PUERPERAL  PERIOD  213 

should  be  washed  out  thoroughly  with  an  antiseptic  solution,  and 
dressed  antiseptically,  and  quinin  should  be  given,  with  a  good  diet, 
and  stimulants  if  necessary. 

What  are  the  chief  causes  of  mastitis? 

Cold,  obstruction  of  milk  ducts,  septicemia,  and  infected  nipples. 

What  affections  of  the  nipples  are  met  with? 

The  nipples  may  be  simply  tender,  or  inflamed,  with  resulting 
abrasions,  excoriations,  and  fissures.  The  inflammation  may  be 
simple,  aphthous,  or  eczematous. 

How  are  sore  nipples  to  be  treated? 

1,  Stop  suckling,  and  have  the  milk  removed  by  a  pump  or  mas- 
sage.    Have  patient  use  a  nipple  shield. 

2.  Apply  astringent  remedies,  or  such  as  act  by  excluding  the  air — 
the  best  applications  are  tannin  and  glycerin,  compound  tincture 
of  benzoin,  collodion — or  wash  the  nipple  with  a  saturated  solu- 
tion of  sodium  bib  orate  and  water  and  apply  aristol  5ij.  in  cacao 
butter  §j,  three  or  four  times  a  day.  All  treatment  is,  however, 
uncertain  if  the  child  is  allowed  to  nurse  while  the  nipple  is  sore. 

What  are  agalactia  and  galactorrhea? 

1.  Agalactia  is  a  suppression  or  greatly  diminished  flow  of  milk. 
The  secretion  of  milk  may  be  augmented  by  the  free  use  of  fluids, 
especially  milk,  and  by  persisting  in  applying  the  child  to  the 
breast.     Attention  to  the  general  health  is  important. 

2.  Galactorrhea  is  an  excessive  secretion  of  milk.  This  may  be 
remedied  by  the  use  of  coffee  and  belladonna,  and  by  a  diet  con- 
sisting of  very  little  liquid  and  more  solid  food.  The  name  is 
sometimes  used  to  denote  incontinence  of  milk  from  want  of 
muscular  tone  in  the  nipples.  This  is  to  be  treated  with  as- 
tringents. 

What  are  the  principal  congenital  defects  in  the  child  which  re- 
quire attention? 

Hare-lip;  imperforate  anus  or  urethra;  spina  bifida;  club-foot; 
cephalhematoma;  patulous  foramen  ovale,  stenosis  or  atresia  of  the 
gall  ducts. 

What  general  rules  are  applicable  to  these  affections? 
I.  Hare-lip  is  to  be  operated  on  at  once,  if  it  interferes  with  suck- 


214  COMPEND   OF   OBSTETRICS 

ling;   otherwise  we  may  wait  a  few  months,   until  the  child  is 
stronger. 

2.  Imperforate  anus  and  urethra  are  to  be  operated  on  at  once, 

3.  The  treatment  of  other  malformations  should  be  begun  as  soon 
as  practicable. 

What  is  a  patulous  foramen  ovale? 

A  failure  of  the  foramen  in  the  auricular  septum  to  close  after 
birth.  Hence  the  blood  is  diverted  from  the  lungs.  The  child  is 
subject  to  spells  of  partial  asphyxia  (rarely  continuous)  and  the 
face  becomes  dusky  or  livid;  hence  the  name  a  "blue  child." 

What  is  to  be  done? 

Treatment  by  posture;  the  child  is  to  be  kept  on  its  right  side, 
that  the  action  of  gravitation  may  hinder  the  escape  of  the  blood 
through  the  foramen. 

What  is  spina  bifida? 

It  is  a  tumor  situated  usually  in  the  sacral  region,  although  it 
may  occur  in  any  part  of  the  spine.  It  contains  cerebrospinal 
fluid,  which  is  covered  in  the  same  manner  as  the  rest  of  the  spinal 
cord.  The  disease  is  caused  by  a  non-development  of  the  vertebral 
arches.  It  is  usually  associated  with  hydrocephalus.  Most  cases 
prove  fatal. 

What  is  cephalhematoma? 

The  term  is  applied  to  an  extravasation  of  blood  either  exter- 
nally, between  the  cranial  periosteum  and  the  bone,  or  internally, 
between  the  dura  mater  and  the  interior  of  the  skull.  It  may  ap- 
pear on  any  of  the  cranial  bones,  but  is  most  common  in  the  parietal 
region.     It  never  passes  a  suture. 

Symptoms. — When  first  appearing  the  tumor  is  tense  and  resist- 
ing, presenting  somewhat  the  appearance  of  a  caput  succedaneum; 
in  a  few  days,  however,  the  borders  become  harder  than  the  rest 
of  the  swelling,  and  soon  become  as  hard  as  bone,  which,  in  fact, 
they  are.  A  slight  internal  cephalhematoma  is  frequently  found  at 
the  same  time.  The  latter,  in  some  cases  where  much  blood  is  ex- 
travasated,  is  an  extremely  dangerous  complication. 

Cause. — In  many  cases  somewhat  obscure,  as  it  frequently  ap- 
pears upon  parts  of  the  head  not  pressed  on  during  labor.  The 
immediate  cause  is  small  sub-periosteal  hemorrhages,  due  to  rup- 
ture of  the  extremely  fragile  vessels,  the  great  mobility  of  the  peri- 


ASPHYXIA   NEONATORUM  215 

osteum  accompanied  by  a  somewhat  hyperemic  condition  of  the 
cranium. 

Diagnosis. — Limitation  to  one  bone,  never  jumping  a  suture; 
its  gradual  increase  after  birth;  caput  succedaneum  decreasing  at 
the  same  period.  The  mobility  of  the  skin.  The  prognosis  in 
external  cephalhematoma  is  good. 

Treatment. — A  compress  containing  some  evaporating  lotion  and 
a  bandage  is  generally  all  that  is  necessary.  When  the  tumor  is 
large  and  persists,  it  is  sometimes  well  to  incise  under  strict  anti- 
septic precautions,  and  wash  out  carefully.  Moderate  pressure 
should  afterward  be  made. 


ASPHYXIA    NEONATORUM 

What  is  asphyxia  neonatorum? 

It  is  a  condition  of  suspended  animation  caused  by  fionareation  of 
the  fetal  blood.  Its  most  common  cause  is  pressure  on  the  umbilical 
cord  before  or  during  birth.  It  may  be  caused  by  tetanic  contraction 
of  the  uterus,  marjked  hemorrhage  in  the  mother  may  also  be  a  cause. 

What  are  the  two  principal  forms  of  asphyxia  neonatorum? 

Asphyxia  livida,  in  which  the  child  is  cyanotic;  the  face  and  skin 
generally  are  of  a  dusky  purple  hue,  the  conjunctivae  are  injected,  and 
the  eyes  protrude.     The' cord  pulsations  are  generally  slow  and  full. 

Asphyxia  pallida,  in  which  the  child  is  pale  and  generally  relaxed; 
the  surface  is  cold  and  the  appearance  anemic. 

How  would  you  treat  a  child  suffering  from  asphyxia? 

In  the  livid  form  cut  the  cord,  allowing  a  dram  or  two  of  blood  to 
escape.  In  asphyxia  pallida  it  is  well  to  press  the  blood  from  the  cord 
toward  the  umbilicus.  The  child  may  be  placed  in  a  hot  bath,  its 
head  supported,  and  a  small  quantity  of  cold  water  dashed  over  the 
chest.  In  the  latter  case  friction  should  be  made  over  the  body  as 
soon  as  the  infant  is  removed  from  the  water. 

How  may  a  child  be  resuscitated  when  apparently  still-born? 

If  it  does  not  at  once  respond  to  spanking  or  dashing  water  upon 

its  chest,  resort  to  the  following  methods  of  resuscitation — 

I.  Byrd's  method  modifiied.     The  physician  sits  with  his  lap  covered 

by  a  rubber  apron  or  oil  cloth.     The  thumb  and  first  finger  of  the 

right  hand  should  lightly  enclose  the  neck  of  the  child  and  the 


2l6 


COMPEND    OF    OBSTETRICS 


fingers  of  the  same  hand  support  the  back,  which,  with  the  head, 
are  lowered  considerably  below  the  level  of  the  body,  the  child 
thus  hanging  head  down.  The  left  hand  clasps  the  buttocks  of 
the  child.  The  body  is  then  bent  forward  on  itself,  thus  pro- 
ducing expiration,   then  freely  extended,   producing  inspiration. 


Fig.  8o. — The  Draeger  Infant  Pulmotor.     For  the  Mechanical  Production 
OF  Artificial    Respiration  in  Cases  of  Asphyxia  Neonatorum. — {Edgar.) 


By  thus  folding  and  unfolding  the  body  a  very  successful  means 
of  artificial  respiration   is  made.     The  lowered   head  determines 
the  child's  blood  to  the  brain,  thus  keeping  the  important  ner\^e 
centers  supplied  with  blood. 
2.  To  Sylvester's  method  of  artificial  respiration.     The  child  is  laid 


CONJUNCTIVITIS    OF   THE    NEWBORN  217 

upon  its  back  with  its  shoulders  sHghtly  elevated.  The  physician, 
standing  at  the  head,  grasps  the  arms  at  the  elbows  and  alternately 
raises  them  above  the  head  and  depresses  them  against  the  chest. 

3.  To  Schultze's  method.  The  obstetrician,  standing,  takes  the  child 
in  both  hands,  with  the  back  of  the  head  pointing  toward  the  opera- 
tor. The  fingers  lie  across  the  back  at  the  scapulae,  with  the 
thumbs  against  the  sides  and  front  of  the  chest.  The  face  now 
looks  upward.  The  child  is  now  raised  until  it  is  above  the  opera- 
tor's head;  in  so  doing  the  lower  part  of  the  trunk  and  extremities, 
as  well  as  the  head,  fall  backward.  By  swinging  the  child  in 
this  manner  the  body  is  alternately  straightened  out  and  doubled, 
causing  a  depression  and  elevation  of  the  diaphragm  and  favoring 
inspiration  and  expiration. 

4.  Mouth-to-mouth  insufflation.  Wipe  the  baby's  face,  compress  the 
nostrils  with  the  fingers  of  one  hand,  and  press  the  other  hand 
upon  its  epigastrium.  Then  apply  your  mouth  to  the  child's  and 
blow  into  it.  The  pressure  of  the  second  hand  prevents  the  air 
from  entering  the  intestines.  A  suitable  pulmonary  aspiration 
apparatus  accomplishes  the  same  result. 

5.  Labord's  method  consists  in  placing  the  infant  on  its  back,  with 
a  rolled-up  towel  under  the  shoulders,  as  in  Sylvester's  method. 
The  head  should  be  allowed  to  hang  low.  The  tongue  is  rhythmic- 
ally drawn  out  and  in  about  as  frequently  as  the  child  would 
breathe.     This  method  has  been  highly  recommended. 

6.  A  galvanic  battery  may  be  used. 

Attempts  at  resuscitation  should  be  continued  as  long  as  there  is 
any  hope  of  success.  If,  however,  no  heart-beats  or  pulsation  of 
any  of  the  arteries  can  be  felt  five  after  or  ten  minutes,  and  the 
body  becomes  progressively  colder,  further  attempts  rarely  do  much 
good. 

7.  The  use  of  a  pulmotor,  an  instrument  for  the  mechanical  produc- 
tion of  respiration  has  proven  useful. 

CONJUNCTIVITIS  OF  THE  NEWBORN 

What  is  conjunctivitis  or  ophthalmia  neonatorum? 

This  is  a  disease  affecting  the  eyes  of  newborn  children,  and  is 
generally  the  result  of  specific  infection  caused  by  the  eyes  of  the  child 
coming  in  contact  with  the  vaginal  secretions  of  the  mother,  who, 
in  most  cases,  has  had  either  purulent  endometritis  or  gonorrhea. 


2l8  COMPEND    OF    OBSTETRICS 

Various  bacteria  may  cause  it,  thus  we  may  have  infection  by  the 
staphylococcus,  pneumococcus  or  the  gonococcus;  the  latter  is  the 
most  virulent. 

What  are  the  symptoms? 

These  appear  about  the  second  to  the  fifth  day.  The  eyelids 
become  slightly  red  and  swollen,  with  a  purulent  secretion.  As  the 
disease  progresses  this  swelling  increases,  the  secretion  becoming  of 
a  thick  yellow  or  green  color,  while  the  conjunctiva  is  greatly  in- 
filtrated, swollen,  and  roughened.  The  cornea  soon  becomes  affected. 
After  six  to  eight  weeks  the  patient  may  recover,  although  chronic 
blennorrhea  is  by  no  means  rare  and  loss  of  sight  common. 

What  is  the  prognosis  of  ophthalmia  neonatorum? 

The  prognosis  depends  on  the  severity  of  the  disease,  the  nature 
of  the  infection,  and  the  time  at  which  the  patient  comes  under  treat- 
ment. With  the  careful  execution  of  prescribed  treatment,  the  dis- 
ease when  taken  in  the  earliest  stages  generally  responds  quickly. 
When  the  cornea  is  affected,  the  danger  of  blindness  is  great. 

Describe  the  treatment  of  ophthalmia. 

The  danger  of  ophthalmia  is  much  decreased  when  the  mother 
receives  an  antiseptic  vaginal  douche  immediately  before  or  during 
labor.  As  prophylaxis,  the  eyes  of  the  child  as  soon  as  it  is  born 
should  be  washed  with  a  saturated  solution  of  boracic  acid,  and  gtt.  j 
of  a  2  per  cent,  solution  of  silver  nitrate  injected  by  means  of  a 
dropper,  the  lids  being  held  apart.  When  the  disease  is  already  in 
progress,  the  eyes  must  be  carefully  washed  out  with  large  quantities 
of  saturated  boric  acid  solution,  and  one  to  three  drops  of  a  solution 
of  silver  nitrate,  as  above,  instilled.  In  severe  cases,  ice  compresses 
should  be  continually  applied  until  the  inflammation  ceases,  with 
strong  solutions  of  boracic  acid  or  bichlorid  of  mercury,  i  :  10,000 
or  12,000,  must  be  used.  If  only  one  eye  is  affected  the  other  eye 
should  be  carefully  protected  not  only  by  frequent  douching  but 
by  pledgets  of  cotton  or  gauze.  A  10  per  cent,  solution  of  argyrol 
may  be  substituted  for  the  silver  nitrate  solution.  The  contagious- 
ness of  this  affection  should  be  impressed  on  the  person  taking  charge 
of  the  case.  She  should  be  cautioned  to  wear  rubber  gloves  and  to 
protect  her  own  eyes.  Under  no  circumstances  should  a  nurse  having 
charge  of  a  case  of  ophthalmia  take  charge  of  a  puerperal  woman. 


THE   UMBILICUS  219 

THE  UMBILICUS 

To  what  diseases  may  the  umbilicus  be  subject? 

The  umbilicus  is  subject  to  various  diseases  and  accidents  after 
detachment  of  the  cord.  Among  these  are  hernia,  infection,  hem- 
orrhage, and  vegetations. 

How  is  umbilical  hernia  caused? 

By  the  non-closing  of  the  umbilical  ring  or  the  lack  of  tone  in 
the  parts.  It  appears  usually  in  the  first  few  weeks  of  extra-uterine 
life,  as  a  small  tumor,  which  increases  when  the  child  cries  or  coughs, 
and  varies  somewhat  with  respiration. 

Describe  the  treatment  of  umbilical  hernia. 

The  treatment  consists  in  replacing  it  and  covering  with  a  large 
button  covered  with  some  soft  material  and  fastened  with  strips 
of  adhesive  plaster.  A  more  recent  treatment  consists  in  drawing 
the  two  sides  of  the  umbilical  opening  together,  so  as  to  relieve 
tension,  and  holding  them  thus  by  strapping  with  narrow  bands 
of  adhesive  plaster.  If  persistent,  a  truss  should  be  fitted  care- 
fully over  the  umbilicus,  or  the  opening  may  be  closed  by  surgical 
procedures. 

Describe  the  cause,  symptoms,  and  treatment  of  septic  infec- 
tion of  the  umbilicus. 

This  appears  when  proper  cleanliness  has  not  been  used  in  the 
care  of  the  stump  of  the  cord,  the  seat  of  its  recent  attachment, 
which  presents  a  surface  open  to  the  absorption  of  septic  material. 
Having  become  infected,  the  borders  of  the  point  of  attachment 
are  red  and  swollen,  and  the  adherent  remains  of  the  cord  black, 
or  brownish-black,  and  moist.  On  inspection  some  pus  will  be 
found  in  the  folds  of  the  ring. 

Treatment. — The  greatest  care  must- be  exercised  in  these  cases; 
for  if  neglected  the  septic  process  will  proceed  inward,  producing 
general  septic  infection  and  death.  The  umbilicus  should  be  washed 
with  a  saturated  solution  of  borax  in  water,  or  hydrogen  peroxid  and 
dusted  with  a  powder  consisting  of  salicylic  acid  and  starch  1:3.  A 
very  good  dressing  is  aristol.  A  small  antiseptic  pad  and  bandage 
should  hold  the  dressing  in  place. 

What  can  be  said  of  umbilical  hemorrhage? 

The  simplest  form  of  this  may  be  caused  by  slipping  of  the  ligature 
holding  the  cord  stump.     Another    and  more  serious,   often  fatal, 
IS 


220  COMPEND    OF    OBSTETRICS 

form  occurs  about  the  period  of  detachmeat  of  the  cord,  from 
the  fifth  to  the  eighth  day  after  birth.  It  is  caused  generally 
by  a  poor  condition  of  the  tissues,  or  hemophilia.  It  is  some- 
times ascribed  to  syphiHs  and  more  frequently  it  occurs  from  in- 
fection, hemophiha,  and  is  one  of  the  symptoms  of  hemoglobin- 
uria or  Winckel's  disease.  It  appears  as  a  continuous  oozing 
from  the  umbilicus,  and  persists  in  spite  of  all  efforts  at  cure. 
It  is  sometimes  accompanied  by  purpuric  spots  on  the  skin.  Hemor- 
rhages often  occur  into  the  stomach  and  intestines.  The  blood  is 
frequently  found  to  be  deficient  in  quality,  and  the  corpuscles  more  or 
less  abnormal.  Treatment  should  be  directed  to  improving  the  condi- 
tion of  the  blood,  and  the  administration  of  styptics,  principally  some 
of  the  preparations  of  iron.  Hemorrhages  from  the  umbiHcus  may 
also  occur  soon  after  birth  from  the  sHpping  of  the  knot  of  the  ligature. 
In  this  case  a  fresh  Ugature  should  be  appHed,  preferably  after  crush- 
ing the  cord  stump  with  a  pair  of  hemostatic  forceps.  In  those  con- 
ditions caused  by  blood  degeneration,  such  as  those  mentioned, 
Winckel's  disease,  etc.,  direct  transfusion  of  blood  may  be  tried  with 
benefit.  As  a  rule  though  the  child  dies  notwithstanding  all 
treatment. 


What  can  be  said  of  vegetations  of  the  umbilicus? 

Vegetations  of  the  umbilicus  frequently  are  seen  around  the  inser- 
tion of  the  cord  after  it  has  become  detached.  They  should  be 
treated  by  silver  nitrate  or  acetic  acid.  Care  must  be  taken  not  to 
mistake  this  condition  for  hernia,  or  in  cases  of  polypoid  growths 
for  a  hernia  of  Meckel's  diverticulum. 


Describe  mastitis  neonatorum. 

Inflammation  of  the  breasts  occurs  sometimes  in  the  newborn. 
The  cases  are  divided  about  equally  among  boys  and  girls.  A 
fluid  resembling  colostrum  can  be  squeezed  out  of  the  nipple.  In 
rare  cases  suppuration  occurs.  The  nipples  are  generally  retracted, 
the  breasts  appearing  hard  and  inflamed.  As  treatment,  careful 
washing  with  a  mild  antiseptic  solution,  accompanied  by  the  applica- 
tion of  lead  water  and  laudanum.  Should  the  swelling  progress  to 
suppuration,  it  should  be  opened,  washed  out  with  an  antiseptic 
solution,  and  covered  with  compress  and  bandage. 


JAUNDICE   OF  THE   NEWBORN  221 

JAUNDICE  OF  THE  NEWBORN 

What  is  icterus  neonatorum? 

A  certain  amount  of  yellowness  appears  on  the  skin  of  many 
newborn  children,  and  usually  disappears  about  the  eighth  or  ninth 
day. 

In  some  cases  the  skin  is  of  a  deep  yellow  hue,  the  color  being 
general,  showing  even  in  the  conjunctivas.  Such  a  condition  con- 
stitutes a  distinct  class  of  diseases,  and  may  be  serious.  Feeble, 
prematurely  born  children,  or  those  who  have  suffered,  for  any  reason, 
traction  or  pressure  on  the  funis  during  labor,  are  chiefly  predisposed 
to  jaundice.  Malformations  of  the  bile  ducts,  syphilis,  and  inflamma- 
tions of  the  gastro-intestinal  tract  are  also  causes.  Jaundice  may  also 
be  a  symptom  in  general  septic  infections  in  the  newborn. 

Treatment. — In  simple  cases  a  regulated  diet  is  sufficient.  In 
all  cases  the  jaundice  appears  chiefly  as  a  symptom,  and  the  cause 
must  be  sought  and  removed  if  possible. 

TETANUS,  OR  LOCKJAW,  IN  THE  NEWBORN 

Describe  the  causes,  symptoms,  and  treatment  of  tetanus  neo- 
natorum? 

This  is  most  apt  to  be  secondary  to  infection  of  the  umbilical 
ring,  and  is  distinctly  a  microbic  disease. 

The  symptoms  appear  as  restlessness  and  tremor  of  the  lower 
jaw;  soon  the  mouth  becomes  closed,  and  cannot  be  opened.  In  a 
short  time  spasms  make  their  appearance,  the  attacks  being  distinctly 
tetanic  in  character.  The  temperature  is  high,  reaching  107-109°  P. 
The  termination  is  fatal,  the  cause  of  death  being  exhaustion  or 
asphyxia.  The  treatment  consists  of  nourishment  by  enema,  and 
potassium  bromid  or  chloral  in  suitable  doses.  Antitetanic  serum 
has  given  good  results  in  many  cases. 

What  is  thrush? 

This  is  a  disease  attacking  the  mucous  membrane  of  the  tongue 
and  mouth,  and  is  characterized  by  the  appearance  of  patches  some- 
what resembling  curd.  It  is  more  common  in  bottle-fed  babies  than 
in  those  fed  from  the  breast.  The  disease  is  caused  by  a  fungus 
belonging  to  the  general  class  of  molds. 

Treatment. — The  best  local  application  is  boracic  acid  in  a  solution 
of  grs.  XX  to  the  fgj  of  water,  and  applied  to  the  buccal  mucous 
membrane  by  means  of  a  camel's-hair  brush. 

The  names  of  Muguet  and  Sprue  are  also  given  to  this  disease. 


APPENDIX  OF  CERTAIN  OBSTETRIC 
CONSTANTS 


OBSTETRIC  CONSTANTS 

ANATOMY  AND  PHYSIOLOGY 

The  female  internal  genital  organs  are  the  ovaries,  oviducts,  uterus 
and  vagina. 

The  female  external  genital  organs  are  the  mons  veneris,  labia 
majora  and  minora,  clitoris,  vestibule  and  fossa  navicularis,  hymen 
or  carunculae  myrtiformes,  fourchette  and  perineum  and  the  breasts. 

The  bones  composing  the  obstetric  pelvis  are  five  in  number — 
last  lumbar  vertebra,  sacrum,  coccyx  and  two  ossa  innominata. 

The  uses  of  the  female  pelvis  are:  (i)  To  support  and  transmit 
the  weight  of  the  body,  (2)  to  contain  and  protect  certain  organs,  (3) 
to  serve  as  a  parturient  tube  or  canal  through  which  the  child  may  be 
guided  during  labor. 

The  differences  between  the  female  and  the  male  pelves  are:  In 
the  female  the  subpubic  arch  is  more  rounded,  the  transverse  diameters 
are  relatively  greater  and  the  antero-posterior  diameter  relatively 
less.  The  transverse  diameter  of  the  inlet  crosses  the  antero-posterior 
at  a  point  in  front  of  the  intersection  of  the  oblique  diameters  and  the 
ischial  spines  are  to  the  outer  side  of  plumb  lines  dropped  from  the 
postero-superior  iliac  spines.  The  bones  of  the  female  pelvis  are 
lighter  in  structure,  the  "flare"  of  the  iliac  bones  is  greater  and  the 
perpendicular  depth  not  so  great  in  the  female  pelvis  as  in  the  male. 

The  joints  in  the  pelvis  are:  three  lumbo-sacral,  two  sacro-iliac,  the 
pubic  and  the  sacro-coccygeal,  seven  in  all. 

The  cardinal  points  of  the  pelvic  inlet,  sometimes  called  the  cardinal 
points  of  Capuron,  are  the  sacro-iliac  joints  and  ilio-pectineal  emi- 
nences on  each  side,  four  in  all. 

The  diameters  of  the  pelvic  inlet  are  the  (i)  antero-posterior  or  sacro- 
pubic  diameter  measured  from  the  promontory  of  the  sacrum  to  the 
middle  of  the  posterior  surface  of  the  pubic  joint,  11  centimeters  or 

222 


APPENDIX  223 

41/2  inches.  It  is  called  the  conjugata  vera  or  true  conjugate.  Ex- 
ternally on  the  surface  of  the  body  this  diameter  is  taken  from  the 
depression  below  the  spine  of  the  last  lumbar  vertebra  to  the  middle 
of  the  anterior  surface  of  the  pubic  joint.  It  measures  20.5  centi- 
meters or  7.9  inches  and  is  known  as  the  external  conjugate;  subtract- 
ing 9  centimeters  or  3.4  inches,  leaves  11.5  centimeters  or  4.5  inches, 
length  of  true  conjugate. 

Vaginally  it  may  be  taken  by  two  fingers  in  the  vagina  measuring 
from  the  promontory  of  the  sacrum  to  the  inferior  border  of  the  an- 
terior surface  of  the  pubic  point  and  deducting  2  centimeters. 

(2)  The  transverse  diameter  of  the  pelvic  inlet  is  taken  between 
the  widest  points  in  the  pelvic  inlet,  12,5  centimeters  or  4.8  inches. 

To  measure  it  externally  two  measurements  are  required: 

(a)  Between  the  anterior-superior  spines  of  the  ilium,  26  centimeters 

or  10.5  inches. 

(&)  Between  the  highest  points  of  iliac  crests  28  centimeters  or  11 

inches. 

(3)  The  transverse  diameter  of  the  pelvic  cavity  is  measured  be- 
tween the  great  trochanters,  32  centimeters  or  12.5  inches. 

(4)  The  right  diagonal  of  the  pelvic  inlet  is  measured  from  the 
right  sacro-iliac  joint  to  the  left  ilio-pectineal  eminence,  13.5  centi- 
meters or  5.3  inches. 

(5)  The  left  diagonal  taken  from  the  left  sacro-iliac  joint  to  the 
right  ilio-pectineal  eminence,  13  centimeters  or  5  inches. 

Externally  the  above  are  measured  from  the  postero-superior  spine 
of  one  side  ot  the  antero-superior  spine  of  the  opposite  side.  The  right 
external  diagonal  measures  22.5  centimeters.     The  left  22  centimeters. 

(6)  The  circumference  of  the  bony  pelvis  is  40  centimeters  or  15.8 
inches.  The  external  circumference  is  85  to  90  centimeters,  33  1/2  to 
35  1/2  inches. 

The  antero-posterior  or  conjugate  diameter  of  the  pelvic  outlet 
is  taken  from  the  tip  of  the  coccyx  to  the  inferior  border  of  the  sym- 
physis pubis.  It  is  greatly  increased  by  the  recession  of  the  coccyx 
in  labor.  Its  normal  measure  is  9.5  centimeters  or  3  3/4  inches.  When 
increased  by  recession  of  the  coccyx  it  measures  13  centimeters  or 
5  inches. 

The  transverse  diameter  of  the  outlet  is  taken  from  one  tuberosity 
of  the  ischium  to  its  fellow  of  the  opposite  side  and  measures  4  inches 
or  1 1  centimeters.     It  is  taken  externally  between  these  points. 

The  depth  of  the  pelvic  cavity  133.8  centimeters  or  i  1/2  inches  iri 


224  COMPEND    OF    OBSTETRICS 

front,  8.9  centimeters  or  3  1/2  inches  at  the  sides  and  10.8  centimeters 
or  41/2  inches  posteriorly.  Following  the  curve  of  the  sacrum  it  is 
13.8  centimeters  or  5  1/2  inches  in  its  posterior  measurement.  The 
average  diameters  are  about  12  centimeters  or  4  3/4  to  5  inches. 

The  planes  of  the  pelvis  are  imaginary  levels  drawn  through  any 
part  ot  the  birth  canal.  They  are  exactly  at  right  angles  to  the  pelvic 
axis  throughout  its  entire  length. 

The  axis  of  the  pelvis  is  an  imaginary  line  drawn  from  the  center  of 
the  conjugate  diameter  of  the  inlet,  parallel  to  the  face  of  the  sacrum 
and  coccyx  to  the  center  of  the  conjugate  diameter  of  the  outlet. 

It  is  a  curved  line  having  a  general  direction  downward,  backward, 
upward  and  forward  and  is  sometimes  known  as  the  curve  of  Carus. 

The  muscles  contained  in  the  pelvis  and  which  modify  its  diameters, 
are  the  psoas  iliacus,  pyriformis,  obturator  internus. 

The  muscles  which  form  the  pelvic  floor  are  the  levatores  ani, 
coccygeus  and  bulbo-cavernosus,  transversus  perinei  or  ischio-bulbosus 
and  external  sphincter  ani. 

The  nerve  supply  of  the  uterus  is  derived  from  the  plexus  uterinus 
magnus,  formed  by  branches  from  the  superior  mesenteric  plexus  and 
from  the  ovarian  ganglia.  The  sympathetic  nervous  system  also 
furnishes  fibers,  the  vasomotor  system  has  much  influence  on  the 
womb.  Independent  ganglia  like  those  found  in  the  heart  are  im- 
bedded in  the  uterine  muscle. 

The  arteries  supplying  the  uterus  are  the  uterine  and  ovarian  arter- 
ies.    The  veins  accompany  the  arteries. 

The  uterus  is  supported  in  situ  by: 

1.  The  utero-sacral  ligaments. 

2.  Slightly  by  the  broad,  round,  and  vesico-uterine  ligaments. 

3.  The  walls  of  the  vagina  act  as  a  fleshy  column  of  support. 

4.  The  retentive  power  of  the  abdomen  due  to  the  existence  of  a 
partial  vacuum  in  the  abdominal  cavity  also  acts  as  a  support. 

EMBRYOLOGY 

The  internal  reproductive  organs  are  developed  from — Wolffian 
bodies,  two  in  number,  Mullerian  ducts,  also  two  in  number. 
Changes  taking  place  in  the  ovum  after  fecundation: 

1 .  When  the  ovum  is  mature  two  smaU.  cells  are  detached  from  the 
main  body  of  cells;  these  are  called  the  polar  globules. 

2.  The  portion  of  the  ovum  remaining  after  the  throwing  off  of  the 
polar  globules  is  called  the  "female  pronucleus." 


APPENDIX  225 

3.  Fecundation  is  effected  by  the  penetration  of  the  head  of  one 
spermatozoon;  this  is  called  the  "male  pronucleus." 

4.  The  male  and  female  pronuclei  coalesce.  The  ovum  is  now 
called  the  "oosperm  or  blastophere." 

5.  The  segmentation  of  the  nucleus  and  vitellus  into  the  mulberry 
mass. 

6.  A  clear  fluid -is  secreted  within  the  ovum,  pressing  these  segments 
to  the  surface,  where  they  form  a  double  layer  of  cells.  The  outer 
is  called  the  epiblast,  the  inner  the  hypoblast.  Later  a  third  layer  of 
cells  develops  between  the  epiblast  and  hypoblast  known  as  the  meso- 
blast.     Together  they  are  known  as  the  blastodermic  vescile. 

7.  There  then  appears  upon  the  outside  of  the  vitellus  the  area 
germinativa. 

8.  In  the  area  germinativa  there  appears  the  primitive  trace. 

9.  A  covering  for  this  line  or  embryo  now  forms,  the  embryonic 
line  sinks  into  the  center  of  the  ovum,  while  the  edges  of  the  external 
blastodermic  layer  about  the  area  close  around  it,  inclosing  it  in  a 
sac  called  the  amnion. 

10.  A  fluid  develops  between  the  amnion  and  the  embryo,  called 
liquor  amnii. 

From  the  epiblast  is  formed: 

The  epidermis,  hair,  nails,  the  epithelium  of  the  mouth,  nose  and 
of  the  cloaca,  glands  of  the  skin,  brain  and  spinal  cord,  organs  of  special 
sense. 

From  the  hypoblast  is  formed: 

Epithelium  of  the  walls  and  glands  of  intestines,  epithelium  of  lungs 
and  air  passages. 

The  mesoblast  furnishes: 

The  corium,  muscles,  bones,  connective  tissue,  muscular  layers  of 
digestive  tract,  blood-vessels  and  the  genito-urinary  system. 

The  placenta  is  developed  in  the  following  manner: 

The  allantois  carrying  with  it  the  blood-vessels  which  are  to  connect 
the  embryo  with  the  periphery  of  the  ovum,  fuses  with  the  chorion 
and  carries  into  each  villus  of  the  latter  a  small  loop  of  blood-vessels. 
The  chorionic  villi  atrophy  over  the  whole  ovum,  except  that  part 
which  is  in  direct  contact  with  the  decidua  serotina  (placental  decidua) . 

The  placenta  is  a  separate  organ  at  about  the  third  month,  and  dur- 
ing this  month  it§  circulation  is  complete. 

The  fetal  circulation: 

The  blood  is  propelled  from  the  left  ventricle  of  the  fetus  through 


2  26  COMPEND    OF    OBSTETRICS 

the  aorta  and  iliac  arteries,  to  the  point  where  the  umbilical  arteries 
are  given  off;  through  these  to  the  placenta,  and  back  again  through 
the  umbilical  vein  to  the  liver,  where  most  of  the  blood  passes  through 
the  portal  circulation  and  empties  by  the  hepatic  vein  in  the  vena 
cava;  the  remainder  passing  through  the  ductus  venosus  empties 
directly  into  the  vena  cava  without  going  through  the  liver.  From 
this  it  enters  the  right  auricle,  and  is  deflected  by  the  Eustachian  valves 
into  the  left  auricle  through  the  foramen  ovale,  and  thence  into  the 
left  ventricle;  to  the  pulmonary  artery  through  the  ductus  arteriosus 
into  the  aorta.  It  will  be  noticed  that  the  venous  blood  of  the  fetus 
is  more  oxygenated  than  the  arterial.  After  birth  the  foramen  ovale 
closes,  and  the  peculiarly  fetal  vessels  disappear. 

CHANGES  IN  POSITION  WHICH  THE  UTERUS  UNDERGOES 
DURING  PREGNANCY 

During  the  first  month  the  increased  weight  causes  it  to  descend 
in  the  pelvis. 

End  of  second  month,  still  low  in  pelvis  and  unusually  anteverted. 

End  of  third  month,  same,  but  a  little  larger. 

End  of  fourth  month,  fundus  can  be  felt  just  above  symphysis. 

End  of  fifth  month,  fundus  midway  between  symphysis  and  um- 
bilicus. 

End  of  sixth  month,  fundus  at  level  of  umbilicus. 

End  of  seventh  month,  2-3  1/2  finger  breadths  above  umbilicus. 

End  of  eighth  month,  1-2  finger  breadths  below  ensiform  cartilage. 

End  of  ninth  month,  touches  the  ensiform  cartilage. 

End  of  tenth  month,  same  as  end  of  eighth. 

SIZE  OF  EMBRYO  AT  EACH  MONTH  IN  CENTIMETERS 


Size  of  E] 

nbryo 

First  month, 

1X1   = 

I  cm. 

Second  month. 

2X2  = 

4  cm. 

Third  month. 

3X3  = 

9  cm. 

Fourth  month. 

4X4  = 

16  cm. 

Fifth  month. 

5X5  = 

25  cm. 

Sixth  month. 

6X5  = 

30  cm. 

Seventh  month. 

7X5  = 

35  cm. 

Eighth  month. 

8X5  = 

40  cm. 

Ninth  month. 

9X5  = 

45  cm. 

280  days  or  ten  months,  10  X  5  =  50  cm. 


APPENDIX 


227 


MENSTRUATION,  ETC. 

Menstruation. — A  periodical  function  of  the  female  genital  organs 
characterized  by  a  discharge  of  blood  from  the  uterus. 

Menorrhagia. — An  abnormally  increased  menstruation. 

Metrorrhagia. — A  hemorrhage  from  the  genital  organs  occurring 
at  other  times  than  the  regular  menstrual  periods. 

Dysmenorrhcea.^^VahihA  or  difficult  menstruation. 

Xenomenia. — Vicarious  menstruation. 

Supplementary  Menstruation  (see  page  41).  ■ 


Ovular 


ABORTION 

The  causes  of  spontaneous  abortion  are: 

Syphilis. 

Placental  apoplexy  and  detachment,  from  hemorrhage. 

Placental  degeneration,  amyloid  or  fatty. 

Dropsy  of  amnion. 

Violence,  accidental  rupture  of  membranes,  etc. 

Obesity. 

Consanguineous  marriages. 

Rapidly  succeeding  pregnancies. 

Hot  climates  and  high  altitudes. 

Syphilis. 

Poisons  either  by  drugs  or  disease.     This  would  include 

all  oxytocic  drugs. 
Habit 

Uterine  displacements. 
Disease  of  the  tubes  and  ovaries. 
Trauma. 
Endometritis. 
Kidney  or  liver  toxemia. 

Syphilis;  especially  syphilitic  spermatozoa. 
Tuberculosis. 
Extreme  youth. 
[  Old  age. 

Symptoms  of  abortion'  are  pain,  hemorrhage  and  uterine  contrac- 
tion. 

General  diagnosis  of  abortion:  Patient  has  the  signs  of  pregnancy, 
there  is  pain,   more  or  less  hemorrhage   and  uterine  contractions. 


Maternal  < 


Paternal 


228 


COMPEND    OF    OBSTETRICS 


Hemorrhage  is  from  the  uterus.     The  os  and  cervix  are  dilated  and 
soft.     Possibly  the  ovum  can  be  felt. 

Indications  for  Therapeutic  Artificial  Abortion. — Eclampsia,  obsti- 
nate uncontrollable  vomiting  of  pregnancy,  bad  and  persistent  cases 
of  albuminuria,  advanced  cases  of  uterine  tumors,  placenta  praevia, 
highly  contracted  pelvis,  and  other  conditions  in  which  the  mother's 
life  is  threatened  by  the  continuance  of  pregnancy. 


Indications  for  Treatment 

1.  Rest  in  bed,  suppository  i  gr.  opium. 

2.  If  hemorrhage  continues,  tampon. 

Differential    Diagnosis    Between    Threatened, 
Incomplete  and  Complete  Abortion 


Inevitable 


Threatened 
Abortion. 


Inevitable 
Abortion. 


Incomplete 
Abortion. 


Complete 
Abortion. 


Hemorriiage,  usu-  Hemorrhage,  pro- 
ally  slight  and  fuse  and  contin- 
free  from  clots.  uous,    clotted    and 

dark  colored. 


Hemorrhage,      per-   Entire  cessation  of 
sistent,     at    times     hemorrhage. 
profuse,    at    times 
scanty;      dark 
colored  and  ofifen- 


sive. 


Pain  not  marked. 


Pain  cramp-like  and    Occasional     attacks 
severe.  j     of    pain    may    be 

present. 


Os     slightly 
lous. 


patu- 


Cervical 
lated. 


canal    di- 


Uterus  soft  and  en- 
•  larged,  showing 
angle  of  ante-! 
flexion  between 
upper  and  lower 
segments. 


Uterus  soft  and  en- 
larged; angle  be- 
tween upper  and 
lower  uterine  seg- 
ments efEaced. 


Cervical  canal  di- 
lated enough  to 
admit  finger, 
which  feels  parts 
of  decidua,  mem- 
branes, or  blood 
clots. 

Uterus  soft,  large, 
and  boggy;  not 
involuting. 


Entire   cessation 
pain. 

Os  retracted. 


of 


Uterus  large  but 
retracted  and  firm. 
Involution  p  r  o  - 
ceeding  naturally. 


Dishcarge  is  bright    Discharge    is    dark 


colored  blood. 


All  signs  of  preg- 
nancy present  ex- 
cept amenorrhea. 


blood,    clots,    and 
portions  of  ovum. 


Examination  of  dis-i  Discharge      is      or- 

charged      material  dinary       lochia, 

shows     only    frag-  which       gradually 

mentary    parts    of  ceases, 
ovum.                         I 


All 


^      „     _        signs    of    preg-    Signs  of  pregnancy 
nancy  present  ex-      nancy  present   ex-      arrested, 
cept  amenorrhea. 


Subsidence  of  signs 
of  pregnancy  and 
possible  establish- 
ment of  milk  secre- 
tion. 


APPENDIX  229 

3.  Dilate  cervix  with  gauze  or  mechanical  dilators. 

4.  Remove  ovum. 

5.  Wash  out  uterus  with  creolin  or  lysol  i  per  cent,  or  normal  salt 
olution  and  pack  with  gauz  e . 

6.  Stimulation,  if  necessary. 
The  dangers  of  abortion  are: 

1.  Hemorrhage— ^of ten  great. 

2.  Retention  of  the  placenta,  either  in  whole  or  in  part. 

3.  The  womb  is  apt  to  remain  enlarged  and  uterine  disease  may 
result. 

4.  Sepsis.  Pelvic  and  peritoneal  inflammations  are  more  common 
after  abortion. 

PLACENTA  PRiEVIA 

The  varieties  of  placenta  previa  are: 

Marginal,  when  its  edge  is  on  the  border  of  the  internal  os. 

Lateral,  when  its  edge  is  alongside  the  internal  os. 

Partial,  when  its  edge  is  partially  over  the  internal  os. 

Central,  when  the  placenta  is  entirely  over  the  internal  os. 

Treatment. — In  all  forms  but  central,  watch  patient  and  if  hemor- 
rhage is  bad  dilate  os,  rupture  membranes  and  by  forceps  bring  down 
head  so  as  to  squeeze  the  placenta,  then  deliver.  Remove  placenta 
and  pack  uterus.  In  central  form  push  placenta  to  one  side  or  tear 
through  it.  Do  quick  podalic  version  and  deliver.  Remove  placenta 
and  pack  uterus  to  prevent  hemorrhage.  Stimulate  patient  as  usual 
in  hemorrhage.  Some  authorities  recommend  vaginal  or  abdominal 
Caesarean  section. 

ECTOPIC  PREGNANCY 

Ectopic  pregnancy  is  pregnancy  in  which  the  ovum  is  developed 
outside  the  cavity  of  the  uterus.  The  most  common  form  is  tubal. 
For  symptoms  see  page  74;  diagnosis,  see  page  75;  prognosis,  see 
page  77. 

Treatment. — Abdominal  section  as  soon  as  diagnosis  is  made. 
After  rupture,  section  in  almost  every  case.  The  only  exception 
being  that  if  rupture  has  occurred  and  a  secondary  abdominal  preg- 
nancy developed  (which  is  extremely  rare),  the  child  being  immature, 
operation  may  be  delayed  until  child  is  viable,  then  section  is  to  be 
done  to  save  child.  When  placenta  is  firmly  attached  and  cannot  be 
removed  without  great  danger  of  hemorrhage,  it  should  be  tied  off, 
the  wound  packed,  and  the  placenta  allowed  to  slough  away. 


230  COMPEND    OF    OBSTETRICS 

SYMPTOMS   OF  PREGNANCY  COMPLICATED  WITH  ANTE- 
DISPLACEMENT 

1.  Nausea  and  vomiting  are  common. 

2.  Frequent  micturition  with  pain. 

3.  Irritability  of  the  bowels. 

4.  Miscarriage. 
Treatment : 

1.  Elevate  uterus  by  means  of  a  pessary  or  large  tampon. 

2.  Operative  procedures. 

3.  Possibly  empty  uterus  in  extreme  cases. 

SYMPTOMS  OF  PREGNANCY  COMPLICATED  WITH  RETRO- 
DISPLACEMENT 

1.  Pain  in  back  and  down  thighs. 

2.  Frequent  and  painful  micturition,  and  if  cervix  presses  long  on 
bladder  actual  cystitis  may  develop. 

3.  Irritability  of  rectum,  constipation  and  sometimes  ribbon-like 
stools. 

4.  Headache  and  nausea  may  occur. 

5.  Abortion,  peritonitis  or  incarceration  may  occur. 
Treatment: 

1.  Knee-chest  position. 

2.  Draw  cervix  downward  with  a  volsella  and  with  two  fingers  of 
the  other  hand  replace  fundus  and  hold  in  place  by  a  pessary  if  no 
adhesions  exist. 

3.  If  uterus  is  adherent  try  to  stretch  adhesions  with  fingers  in 
posterior  cul-de-sac  and  replace. 

4.  If  this  cannot  be  done,  tampons  of  cotton  or  lamb's  wool  satu- 
rated with  30  per  cent,  ichthyol  in  glycerin  may  be  used. 

5.  Open  abdomen  or  posterior  cul-de-sac,  break  up  adhesions  and 
replace. 

6.  Empty  uterus. 

7.  In  extreme  cases  hj^sterectomy  may  be  necessary. 

Malignant  deciduoma  or  corio-epithelioma  is  a  malignant  degenera- 
tion of  retained  decidual  debris  characterized  by  a  tendency  to 
the  formation  of  metastatic  deposits  throughout  the  body.  It  is 
usually  fatal.  Is  also  known  as  malignant  syncytioma.  The  treat- 
ment is  hysterectomy. 


APPENDIX  231 

TOXEMIA  OF  PREGNANCY 

The  toxemia  of  pregnancy  is  an  auto-intoxication  produced  by- 
poisons  generated  in  the  system  and  not  eHminated,  principally 
through  faulty  action  of  the  liver,  skin,  lungs,  kidneys  and  intestines. 
It  may  or  may  not  be  associated  with  disease  of  the  kidneys. 

Symptoms: 

1.  Constant  dull  frontal  headache  with  flashes  of  light  and  sparks 
flying  before  eyes. 

2.  Substernal  distress. 

3.  Pulse  of  high  tension. 

4.  In  some  cases  a  very  slight  elevation  of  temperature. 

5.  Dry  skin  and  coated  tongue. 

6.  Nervousness  or  some  mental  change. 

7.  Specific  gravity  of  urine  decreases.  Decrease  in  urea  and  solids 
generally,  casts  and  albumin  often  present. 

8.  If  the  condition  is  not  relieved  eclamptic  convulsions  usually 
develop. 

Treatment: 

1.  Increase  elimination  by  hot  baths  or  hot  packs.  Diet  of  milk, 
bread  and  fruits. 

2.  Some  cases  hypodermoclysis  or  saline  transfusion. 

3.  Veratrum  viride,  Til  xv,  by  hypodermic. 

4.  Fresh  air. 

5.  A  reasonable  quantity  of  water. 

6.  Give  brisk  purgative  with  calomel  gr.  V  with  salines. 

7.  Enteroclysis,  repeated  several  times  and  until  bowels  are  thor- 
oughly unloaded. 

8.  For  nervous  condition  bromides  or  small  doses  of  chloral  hydrate. 
If  patient  is  anemic  Basham's  mixture. 

9.  Free  diuresis  and  diaphoresis. 

10.  In  some  cases  it  may  be  necessary  to  empty  uterus.  Vaginal 
or  abdominal  Caesarean  section  is  often  practised  if  the  patient  is  in 
an  eclamptic  convulsion. 

Polyhydramnios  or  hydramnios  (see  pages  92  arid  93). 

SIGNS  OF  PREGNANCY,  DIAGNOSIS  OF  PREGNANCY 

(P.  93,  ETC.) 

Pregnancy  is  that  condition  in  which  a  woman  contains  within  her 
body  a  living  or  growing  fetus. 


232  COMPEND   OF   OBSTETRICS 

Signs: 

1.  Presumptive  and  certain. 

2.  Objective  and  subjective. 

The  most  valuable  subjective  signs  are: 

1 .  Cessation  or  change  in  the  menstrual  function. 

2.  Nausea  and  vomiting. 

3.  Enlargement  of  breasts. 

4.  Frequent  micturition  or  desire  to  go  to  stool. 

There  are  many  other  subjective  symptoms  of  less  value. 
The  objective  symptoms  of  early  pregnancy,  i.e.,  before  the  fetal 
heart  sounds  can  be  heard,  are  the  following: 

1.  Unilateral  enlargement  of  uterus. 

2.  Increase  in  size  of  uterus  with  change  in  shape  of  the  body,  it 
becoming  more  globular. 

3.  Softening  and  relative  broadening  of  the  cervix. 

4.  Formation  of  the  lower  uterine  segment  (Hegar's  sign). 

5.  Bluish  discoloration  of  the  cervix,  vagina  and  lesser  labia  with 
increased  secretion. 

6.  Pigmentation  of  the  labia  majora,  central  abdominal  line  and 
mammary  areola  and  other  parts  of  body. 

7.  Increase  in  size  of  thyroid  gland. 

8.  Ballottement. 

9.  Intermittent  contraction  of  uterus  (Braxton  Hicks'  sign). 
The  certain  signs  (to  be  found  after  the  twenty-sixth  week)  are: 

1.  Symmetrical  enlargement  of  uterus. 

2.  Fetal  heart  sounds. 

3.  Recognition  of  fetal  movement  by  palpation. 

4.  Recognition  of  fetal  parts  by  palpation. 

5.  Placenta,  or  in  some* cases,  the  funic  souffle. 

DIFFERENTIAL    DIAGNOSIS    BETWEEN    PREGNANCY    AND 

OTHER  TUMORS 

Differential  Diagnosis  of  Abdominal  Tumors 

Small  cysts  of  the  ovary  may  be  confounded  with: 

1.  Pregnancy. 

2.  Extra-uterine  pregnancy. 

3.  Distended  Fallopian  tube. 

4.  Inflammatory  exudation  into  the  broad  ligament. 

5.  Peritonitic  exudation. 

6.  Tuberculous  peritonitis. 


APPENDIX 


233 


Large  cysts  occupying  the  greater  part  of  the  abdominal  cavity 
may  be  mistaken  for: 

1.  Ascites. 

2.  Pregnancy. 

3.  Fibroid  tumors  of  the  uterus. 

4.  Fibrocysts  of.^the  uterus. 

5.  Fat  in  the  abdominal  wall. 

6.  Hematometra. 

7.  Phantom  tumors. 


Extra-uterine  (Tubal)  Preg- 
nancy 

1.  Rapid  and  regular  growth. 

2.  Amenorrhea,  followed  by  men- 
orrhagia,  with  discharge  of 
pieces  of  decidua. 

3.  General  symptoms  of  preg- 
nancy present,  changes  in 
color  of  vagina,  etc. 

4.  Enlargement  of  the  uterus. 

5.  Attacks  of  pain  increasing  in 
severity,  finally  culminating 
in  a  very  severe  attack,  fol- 
lowed by  shock  and  symp- 
toms of  internal  hemorrhage. 

Distended  Fallopian  Tube 

1 .  The  tumor  is  more  elongated. 

2.  Is  intimately  connected  with- 
the  uterus,  which  is  more  or 
less  fixed. 

3.  Tumor  is  sensitive  to  pres- 
sure. 

4.  History  of  acute  inflammation 
and  considerable  pain. 

Inflammatory  Exudation  into 
the  Broad  Ligament 

I.  History  of  inflammation  fol- 
lowing miscarriage,  parturi- 
tion, or  operation. 


Small  Ovarian  Cyst 

1.  Slower  growth. 

2.  Menstruation  not  altered  ex- 
cept occasionally  in  broad-liga- 
ment cysts. 

3.  Symptoms  of  pregnancy  ab- 
sent. 

4.  No  enlargement  of  the  uterus. 

5.  In  small  cysts,  no  attacks  of 
pain  except  from  pressure. 


Small  Ovarian  Cyst 

1.  Tumor  is  round. 

2.  Is  not  connected  with  the 
uterus  except  by  the  tube, 
which  is  not  increased  in  size. 

3.  Tumor  non-sensitive. 

4.  No  history  of  acute  inflam- 
mation and  little,  if  any,  pain. 

Small  Ovarian  Cyst 


I.  No  such  history. 


234 


COMPEND    OF    OBSTETRICS 


Peritoxitic  Exudate 

1.  The  tumor  is  sensitive  to 
pressure,  is  fixed,  and  is  gen- 
erally found  in  Douglas's  cul- 
de-sac. 

2.  The  uterus  is  fixed  and  feels 
as  if  set  in  some  hard  sub- 
stance. 

3.  History  of  acute  inflamma- 
tion. 

Ascites 

1.  Swelling  bilateral  and  more 
diffuse. 

2.  Percussion  gives  a  tympanitic 
note  in  front  and  above  the 
tumor,  with  dullness  over  the 
flanks. 

3.  Percusion  note  varies  by 
placing  patient  in  different 
positions. 

4.  Abdomen  flattens  when  pa- 
tient Hes  down  on  her  back. 


Small  Ovarian  Cyst 

1.  The  tumor  is  not  sensitive,  is 
somewhat  mobile,  and  in  small 
cysts  is  lateral. 

2.  The  uterus  is  freely  movable. 


3.  No  history  of  acute  inflam- 
mation. 

Large  Ovarian  Cyst 

1.  Swelling  is  central  or  uni- 
lateral and  is  circumscribed. 

2.  Percussion  gives  dullness  over 
the  tumor,  and  a  clear  or  tym- 
panic note  at  the  flanks  and 
above.     (Coronal  resonance.) 

3.  Little  or  no  variation  when 
position  of  patient  is  changed. 

4.  Abdomen  alwa^^s  prominent. 


Note. — Ovarian  cysts  communicating  with  the  intestine,  or  which 
have  undergone  suppuration,  sometimes  contain  gas,  and  may  give 
a  tympanic  note  on  percussion.  When  the  cyst-wall  is  very  tense, 
a  tympanitic  note  may  be  transmitted  to  the  surrounding  intestines. 
When  such  a  condition  is  suspected,  more  information  can  be  obtained 
by  percussing  lightly. 


3- 


4- 


Pregnancy 

The  tumor  is  more  symmetric 

and  is  central. 

Subjective  signs  of  pregnane}^ 

present. 

The  enlarged  uterus  can  easily 

be  outlined  and  composes  the 

tumor. 

Amenorrhea  is  present. 


Large  Ovarian  Cyst 

1.  Tumor  is  rather  more  lateral. 

2.  Subjective  signs  of  pregnancy 

absent. 

3.  The  uterus  is  small,  and  the 
tumor  is  separate  from  it. 

4.  Menstruation  is  unchanged  or 
may  be  increased. 


APPENDIX 


23s 


5.  Patient's  general  health  good. 

6.  Hearing  the  fetal  heart  and 
outlining  the  fetal  parts  will 
settle  the  diagnosis. 

Uterine  Fibroid 

1 .  Tumor  is  hard,  resisting,  non- 
fluctuating,  and  of  slower 
growth. 

2.  Tumor  is  growing  from  the 
uterus,  and  therefore  moves 
with  it. 

3.  Some  enlargement  of  the 
uterus. 

4.  Menorrhagia  generally  pres- 
ent. 

5.  Uterine  canal  increased  in 
length. 


5.  General  health  of  patient  bad, 

6.  Fetal  heart-sounds  are  absent, 
and  no  fetal  parts  can  be  out- 
lined. 

Large  Ovarian  Cyst 

1.  Tumor  is  fluctuating,  softer, 
and  of  more  rapid  growth  than 
fibroid  tumors. 

2.  Tumor  not  connected  directly 
with  the  uterus. 

3.  Uterus  not  enlarged. 

4.  Menorrhagia  not  generally 
present. 

5.  No  increased  length  of  the 
uterine  canal. 


The  differentiation  between  fibrocystic  tumors  of  the  uterus  and 
ovarian  cysts  is  very  difficult  and  in  many  cases  impossible.  The 
discovery  of  other  fibrous  tumors  of  the  uterus  will  aid  in  the  diagnosis. 


Fat  in  the  Abdominal  Wall 

1 .  Usually  occurs  after  the  meno- 
pause. 

2.  Fat  may  be  grasped  between 
the  two  hands. 


3.  Deposits  of  fat  in  other  parts 
of  the  body. 

4.  Does  not  fluctuate. 

5.  General     health     of     patient 
good. 

Phantom        Tumor — Spurious 
Pregnancy 

r.  General    resonance    over    the 
abdomen. 
16 


Large  Ovarian  Cyst 
Occurs   during   the  period    of 
sexual  activity. 

Cannot  be  grasped  in  the 
same  manner,  but  shows  the 
outline  of  a  circumscribed 
tumor. 

Patient  is  increasingly  ema- 
ciated. 

Fluctuation  may  be  obtained. 
General  health  bad. 


Large  Ovarian  Cyst 

I.  Dullness  over  tumor  and  pres- 
ence of  coronal  resonance  only. 


236 


COMPEND    OF    OBSTETRICS 


By   distracting    the   patient's 

attention  the  abdomen  may 

be  depressed  flat. 

The  tumor  disappears  under 

anesthesia. 

Hematometra 

Regular  attacks  of  pain,  in- 
creased during  the  time  when 
menstruation  ought  to  appear. 
Menstruation  very  scant  or 
absent. 

Tumor  central  and  formed  by 
the  distended  uterus. 
Tumor  decreases  in  size,  some- 
what, between  the  menstrual 
epochs. 

Atresia  of  the  vagina  or  cervix 
present. 


2.  Tumor  does  not  disappear, 
and  the  abdomen  cannot  be 
pressed  flat. 

3.  Tumor  does  not  disappear 
under  anesthesia. 

Ovarian  Cyst 

1.  No  pain  except  from  pressure 

2.  Menstruation  present. 

3.  Bulk  of  tumor  lateral  and 
separate  from  the  uterus. 

4.  Tumor  grows  continually. 

5.  Absent. 


The  fetal  heart  sounds  average  120  to  160  a  minute. 

For  the  more  accurate  location  of  the  fetal  heart  sounds  the  mother's 
abdomen  is  divided  by  two  imaginary  lines — one  from  ensiform 
cartilage  to  middle  of  pubic  joint,  the  other  a  transverse  line  drawri 
across  the  abdomen  on  a  level  with  the  umbilicus.  These  lines  divide 
the  uterus  into  four  quadrants. 

Position  is  the  relation  which  the  presenting  part  of  the  fetus  bears 
to  the  four  cardinal  points  on  the  pelvic  inlet. 

Presentation  is  that  part  of  the  fetus  which  presents  or  comes  first 
at  the  pelvic  inlet. 

Brow,  parietal,  and  other  abnormal  presentations  can  rarely  be 
diagnosticated  except  by  vaginal  examination. 


APPENDIX 


237 


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APPENDIX 


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240 


COMPEND   OF   OBSTETRICS 


to 
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to 

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t 

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Forehead     in     relation 
with    mother's    left    ilio- 
pectineal  eminence.  Chin 
a    right  sacro-iliac  joint. 
Other     points    same     as 
above. 

Buttocks  can  be  felt  at 
inlet.     The      anus      and 
genitals  may  be  felt. 

6 
m 

0 

H 
<! 

PL, 

a! 

Back  of  child  to  mother's 
left      side.     Other     points 
same  as  above,  substituting 
right  for  left  and  left  for 
right. 

The    abdomen    is    more 
prominent     in     its     upper 
part.     The   hard   resistant 
breech  can  be  palpated  at 
the       pelvic      brim.       The 
broad    curved    outlines    of 
the    back    can    be    plainly 
made  out  on  the  left  side 
of  the  mother's  abdomen. 
The  head  can  be  outlined 
at  the  upper  part  of  the 
uterine  tumor.     Long  axis 
of  child  coincides  with  long 
axis  of  mother. 

to 
to    . 

i.i 

CO  ;3 

2J 

0 

1 

0 

Heart     sounds     in     left 
lower  quadrant  but  higher 
than  in  L.  0.  A. 

Heart  sounds  are  heard 
best     in     the     left     upper 
quadrant  near  the  perpen- 
dicular line. 

Heart    sounds    are    heard 
best  in  right  upper  quad- 
rant neart  he  perpendicular 
line. 

0 

Hi 

Right       mento-posterior 
or     left        fronto-anterior, 
by  some  called  first  position 
of    face.     Chin    is    at    the 
right  sacro-iliac  joint,  fore- 
head  at   left   ilio-pectineal 
eminence. 

1st  position.  Left   sacro- 
anterior  (L.    S.   A.).     Sac- 
rum of  child  is  in  relation 
with     mother's     left     ilio- 
pectineal     eminence.     Bis- 
trochanteric    diameter    of 
child    is    in    mother's    left 
oblique. 

2d          position,      Right 
sacro-anterior.           Sacrum 
of  child  is  in  relation  with 
the       right       ilio-pectineal 
eminence.       Bistro  c  h  a  n  - 
teric    diameter   is   in   rela- 
tion   with    mother's    right 
oblique. 

0 

PQ 

APPENDIX 


241 


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242 


COMPEND    OF   OBSTETRICS 


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p^ 


I  CO 


APPENDIX 


243 


5  cm.,  4.5    in. 

5  cm.,  3.75111. 

5  cm.,  3.25  in. 

5  cm.,  3.75  in. 

cm.,  4        in. 

5  cm.,  3.75111. 

5  cm.,  3.25  in. 

5  cm.,  3        in. 

5  cm.,  14.75  in- 


DIAMETERS  OF  FETAL  HEAD   (P.  121) 

Occipito-mental,  13.5  cm.,     5.25  m 

Occipito-frontal,  1 1 

Suboccipito-bregmatic,  9 

Fronto-mental,  8 

Cervico-bregmatic,  9 

Cervico-f  rental,       '  10 

Biparietal,  9 

Bitemporal,  8 

Bimastoid,  7 

Large  circumference  from  chin  to  vertex,  37 

Small     circumference     at     suboccipito-bregmatic 

circumference,  33      cm.,  13         in. 

SYNOPSIS  OF  THE  MECHANISM  OF  LABOR  IN  THE 
VARIOUS  POSITIONS  AND  PRESENTATIONS 

LEFT  OCCIPITO -ANTERIOR 
First  Position  of  Vertex 

1.  Engagement. — Occipito-frontal  diameter  in  relation  with  right 
oblique  of  mother's  pelvis.  Occiput  in  relation  with  mother's  left 
ilio-pectineal  eminence. 

2.  Descent. 

3.  Flexion.  Suboccipito-bregmatic  diameter  in  relation  with  right 
oblique  when  flexion  is  complete. 

4.  Rotation  of  occiput  under  pubic  arch  from  left  to  right. 

5.  Birth  of  head  by  extension. 

6.  Restitution.     Head  rotates  to  left  side  after  birth. 

7.  Right  shoulder  swings  anteriorly,  shoulder  rotating  from  right 
to  left.     Left  shoulder  posterior  sweeps  over  pelvic  floor. 

8.  Birth  of  shoulders  by  lateral  flexion  followed  by  birth  of  body. 

RIGHT  OCCIPITO-ANTERIOR 
Second  Position  of  Vertex 

I.  Engagement. — Occipito-frontal  diameter  in  relation  with  mother's 
left  diagonal.  Occiput  in  relation  with  mother's  right  ilio-pectineal 
eminence. 

Same  mechanism  as  in  first  position  except  that  head  rotates  from 
right  to  left  and  shoulders  from  left  to  right.  Left  shoulder  is 
anterior.     Right  shoulder  posterior. 


244  COMPEND    OP    OBSTETRICS 

OCCIPITO-POSTERIOR  ROTATION,  RIGHT  AND  LEFT 

In  98  per  cent,  of  these  the  occiput  will  rotate  anteriorly  if  time 
enough  is  given.  If  head  rotates  posteriorly  and  is  small  in  relation 
to  pelvis  it  may  be  born  in  extension  over  perineum,  usually  tearing 
through  the  latter. 

The  treatment  of  posterior  rotation  of  the  occiput  should  be  divided 
as  follows: 

I.  Cases  in  which  the  occiput  tends  to  rotate  posteriorly,  but 
finally  ends  in  anterior  rotation :  (a)  Stimulate  patient,  {h)  place  her 
on  the  side  toward  which  the  occiput  of  child  points. 

(c)  Try  to  rotate  by  the  hand. 

{d)  Try  to  rotate  the  occiput  anteriorly  by  forceps. 

{e)  Podalic  version  may  be  done. 

If  the  occiput  rotates  posteriorly,  deliver  by  axis  traction  forceps. 
The  head  is  delivered  in  flexion. 

If  the  head  becomes  impacted  craniotomy  must  be  done. 

FACE  PRESENTATION 
LEFT  MENTO -ANTERIOR 

First  Position 

Fronto-mental  diameter  in  relation  with  right  diagonal.  Chin 
in  relation  with  mother's  left  ilio-pectineal  eminence. 

1.  Descent. 

2.  Complete  extension. 

3.  Rotation  of  chin  from  left  to  right  under  pubic  arch. 

4.  Birth  of  head  in  flexion. 

5.  External  rotation  of  head  and  internal  rotation  of  body 
(restitution). 

6.  Delivery  of  body  by  lateral  flexion.  Left  shoulder  engages 
first  under  pubic  arch. 

RIGHT  MENTO -ANTERIOR 
Second  Position  of  Face 

Fronto-mental  diameter  is  in  relation  with  mother's  left  diagonal. 
Chin  is  in  relation  with  mother's  right  ilio-pectineal  eminence. 

Mechanism  same  as  above  except  chin  rotates  from  right  to  left. 
Right  shoulder  engages  first  under  pubic  arch. 


APPENDIX  245 

LEFT  MENTO -POSTERIOR,   CALLED    SOMETIMES  RIGHT 
FRONTO -ANTERIOR 

Forehead  in  relation  with  mother's  right  iHo-pectineal  eminence, 
chin  at  left  sacro-iliac  joint. 

1.  Head  enters  in  complete  extension. 

2.  Descent. 

3.  Rotation  of  chin  anterior  under  pubic  joint  from  left  to  right. 
If  chin  does  not  rotate  anteriorly  labor  ceases  and  head  becomes 
impacted. 

4.  Birth  of  head  in  flexion. 

5.  Restitution.  As  head  is  born  left  shoulder  swings  from  left 
to  right  into  inlet. 

6.  Left  shoulder  engages  first  under  pubic  arch. 

7.  Birth  of  body  by  lateral  flexion. 

RIGHT  MENTO -POSTERIOR  OR   LEFT   FRONTO -ANTERIOR 

Same  as  above  except  that  after  head  is  born,  right  shoulder  swings 
from  right  to  left  under  pubic  arch.     Right  shoulder  engages  first. 
The  treatment  of  face  presentations  is  as  follows : 

1.  If  pelvis  and  head  are  of  relative  size  and  chin  is  rotating 
anteriorly.     Preserve  membranes,  support  patient  and  let  alone. 

2.  If  chin  rotates  anteriorly  and  labor  is  prolonged,  deliver  by  axis 
traction  forceps  in  flexion. 

3.  If  chin  does  not  rotate  anteriorly  try  to  push  up  chin  and  convert 
into  a  vertex  presentation. 

4.  Try  to  extend  chin  and  aid  anterior  rotation. 

5.  Podalic  version  may  be  done. 

6.  Bring  down  occiput  sufficiently  to  do  craniotomy. 

BREECH,  FIRST  POSITION 

Left  Sacro-anterior. — Sacrum  is  in  relation  with  left  ilio-pectineal 
eminence. 

1.  Compression  or  molding. 

2.  Descent. 

3.  Rotation  of  left  hip  under  pubic  joint. 

4.  Internal  rotation  of  body,  and  head  rotates  from  left  to  right 
until  occiput  is  under  pubic  arch. 

5.  Delivery  of  head  in  flexion. 


246  COMPEND    OF    OBSTETRICS 

BREECH,  SECOND  POSITION 

Right  Sacro-anterior. — Sacrum  in  relation  with  right  ilio-pectineal 
eminence. 

Mechanism  same  as  above,  substituting  right  for  left  and  left  for  right. 
Left  Posterior  Rotation  of  Sacrum. — Sacrum  is  at  left  sacro-iliac  joint. 
Right  Posterior  Rotation. — Sacrum  is  at  right  sacro-iliac  joint. 
Mechanism  same  as  in  first  position  except   management  of  head 
Management  of  breech  presentation: 

1.  Preserve  membranes. 

2.  Support  patient's  strength. 

3.  As  soon  as  body  is  born,  cover  with  a  warm  towel,  to  prevent 
respiration.     Draw  cord  down  so  it  will  not  be  pinched. 

4.  Bring  down  arms. 

5.  After  hips  are  born  raise  them  slightly  toward  the  opposite  groin 
of  the  mother  so  as  to  bring  the  posterior  shoulder  into  the  inlet. 

6.  When  occiput  rotates  anteriorly  deliver  child  by  raising  body, 
back  of  child  toward  mother's  abdomen.  Head  born  in  flexion. 
Any  of  the  methods  for  delivery  of  after-coming  head  may  be  used. 

7.  When  occiput  rotates  posteriorly  the  mother  may  be  laid  on 
the  side  and  the  child's  body  being  born  to  the  waist  may  be  first 
carried  slightly  backward  to  engage  the  shoulders,  after  this  press 
down  over  the  pubic  joint  while  the  body  is  carried  forward,  abdo- 
men of  child  toward  the  abdomen  of  the  mother.  In  many  cases 
the  occiput  may  be  rotated  anteriorly  if  care  is  used. 

Transverse  positions  and  presentations  practically  have  no  mech- 
anism and  must  be  treated  by  version  or  embryotomy.  Sometimes 
these  may  be  delivered  by  vaginal  or  abdominal  section  if  the  child  is 
strong,  the  mother  uninfected  and,  in  the  case  of  vaginal  section,  the 
child  and  pelvis  are  of  relative  size.  Hospital  facilities  should  be 
at  hand. 

Abnormal  presentations,  such  as  brow  and  parietal  presenta- 
tions, occur  mostly  in  contracted  pelves  and  must  be  treated  by 
converting  into  vertex  or  face,  otherwise  craniotomy  must  be  done. 
See  treatment  of  these  conditions. 

DYSTOCIA 

Causes. — Excessive  sense  of  pain,  weak  uterine  contractions,  rigidity 
of  the  OS,  edema,  atresia  or  displacement  of  uterus,  atresia  of  vagina, 
rigid  perineum,  tumors,  hernia  and  deformities  of  the  pelvis. 

Treatment. — See  page  144. 


APPENDIX    •  247 

ABNORMAL  PELVES 

(i)  Generally  enlarged  pelves,  justo  major,  (2)  generally  con- 
tracted pelves,  justo  minor.  (3)  Flat  pelves,  {a)  simple  flat,  (6) 
rhachitic  flat.  (4)  Transversely  contracted  pelves.  (5)  Obliquely 
contracted  pelves  by  luxation.  Obliquely  contracted  pelves  by 
hip-joint  disease.     Obliquely  contracted   pelves  by  kypho-scoliosis. 

Funnel-shaped  Pelvis. — Kyphotic  pelvis,  antero-posterior  diameter 
changed.     Lordotic  pelvis. 

Compressed  Pelvis. — Changed  from  rhachitis  or  osteomalacia. 
Spondylolisthitic  pelvis,  inlet  narrowed  by  slipping  forward  of  the 
last  lumbar  vertebra  on  the  sacrum.  Pelvis  narrowed  by  exostoses 
etc. 

Most  common  form  of  contracted  pelvis  is  the  justo-minor  pelvis. 

Most  common  form  of  flat  pelvis  is  the  simple  flat  pelvis. 

Most  common  form  of  deformed  pelvis  is  the  rhachitic  flat  pelvis. 

Treatment  of  Labor  in  Contracted  Pelves. 

1.  In  justo-minor  pelves  whose  internal  conjugate  is  over  31/2 
inches,  9  centimeters,  induce  labor.  Especially  indicated  in  multi- 
gravida  who  have  lost  previous  children  in  labor  on  account  of  con- 
tracted pelves. 

2.  Symphysiotomy  is  indicated  when  conjugate  is  3  1/4  inches, 
8.5  centimeters.     This  operation  is  not  as  much  used  as  formerly. 

3.  Abdominal  Caesarean  section  is  indicated  in  cases  where  con- 
jugate is  under  3  inches,  8  centimeters. 

4.  In  cases  of  slight  general  contraction  the  child  may  be  de- 
livered by  forceps.  Version  as  a  rule  is  not  indicated.  Positional 
methods  such  as  Walcher's  position  may  be  used. 

Treatment  of  Labor  in  Flat  Pelves. 

1.  Forceps  for  slight  degree  of  contraction. 

2.  Podalic  version. 

3.  Positional  methods  such  as  Walcher's,  etc. 

4.  Symphysiotomy  or  Caesarean  section. 

5.  Craniotomy. 

Treatment  of  Labor  in  Obliquely  Contracted  Pelves. 

1 .  Try  to  bring  down  head  in  long  oblique  diameter. 

2.  Podalic  version. 

3.  Operative  procedures  or  craniotomy. 

Highly  deformed  pelves  require  delivery  by  abdominal  Caesarean 
section.  '  ' 


248 


COMPEND   OF   OBSTETRICS 


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APPENDIX  249 

DIFFERENTIAL   DIAGNOSIS   BETWEEN   TWIN    PREGNANCY 
AND  POLYHYDRAMNIOS 

Twin  Pregnancy, 

1.  Abdominal  tumor  is  broader,  more  distended  at  sides  with 
a  sulcus  in  the  median  line. 

2.  Palpation  may  demonstrate  the  presence  of  two  fetal  bodies. 

3.  By  auscultation  two  fetal  heart  sounds  will  be  heard. 

4.  Fetal  movements  may  be  made  out  at  two  separate  points. 
Polyhydramnios. 

1.  The  tumor  is  rounder. 

2.  By  palpation  the  fetal  body  can  be  outlined  with  difficulty, 
the  largest  part  of  the  tumor  being  fluid. 

3.  Only  one  fetal  heart  sound  can  be  made  out  and  that  with 
difficulty.    The  heart  sounds  are  muffled. 

4.  Fetal  movements  can  be  detected  at  only  one  point. 
Post-partum  hemorrhage  (see  page  163). 

Rupture  of  the  uterus  (see  page  166). 

FORCEPS 

Indications  for  Use. — Whenever  the  life  of  mother  or  child  or  both 
are  in  danger  from  the  continuance  of  labor,  providing  the  child's 
head  and  mother's  pelvis  are  of  relative  size,  the  head  is  presenting 
and  preferably  engaged  in  the  pelvis,  and  the  os  fully  dilated  or  capa- 
ble of  dilatation. 

The  low  application  of  forceps  is  used  when  the  child's  head  is  on 
the  pelvic  floor. 

The  high  application  is  used  when  the  child's  head  is  above  the 
pelvic  floor.     For  this  purpose  axis  traction  must  be  used. 

The  line  of  traction  with  the  obstetric  forceps  is  downward  and 
backward  (with  axis  traction)  until  the  head  has  reached  the  pelvic 
floor,  then  upward  and  forward  (with  handles  raised  toward  pubic 
bone). 

Method  of  Application. — The  patient  being  properly  prepared  and 
under  an  anesthetic,  preferably  ether,  the  bowels  and  bladder  being 
emptied,  the  latter  by  catheter,  and  the  head  in  vertex  anterior 
position  and  presentation,  introduce  the  left  blade  held  in  the  left 
hand,  guided  by  the  right  hand,  introduced  into  the  vagina  to  the 
left  side  of  the  mother's  pelvis,  then  the  right  blade  in  the  operator's 


250  COMPEND    OF    OBSTETRICS 

right  hand,  guided  by  the  left  hand,  to  the  right  side  of  the  mother's 
pelvis.  The  blades  must  be  fitted  to  the  sides  of  the  fetal  head  and 
traction  made  in  the  line  of  the  birth  canal.  For  other  presentations 
see  pages  181  to  184. 


INDEX 


Abderhaldens'  test  for  pregnancy,  94 
Abdominal  Cesarean  section,  191 

pregnancy,  73 
Abnormalities  of  the  placenta,  87 
Abortion,  63 

artificial,  63 

causes  of,  64 

complete,  63 

criminal,  63 

dangers  of,  65 

diagnosis  of,  65 

embryonic,  63 

incomplete,  63 

inevitable,  63 

missed,  63 

spontaneous,  63 
causes  of,  63 

symptoms  of,  64 

table  showing  differential  diagnosis 
between  threatened,  inevitable, 
incomplete  and  complete,  65 

therapeutic,  63 
indication  for,  64 
method  of  inducing,  67 

threatened,  63 

treatment  of,  66 
Accessory  ovaries,  29 
Accidental  hemorrhage,  67,  162 
Accouchement,  i 
Adherent  placenta,  172 
After  pains,  118 
Agalactia,  213 

Albuminuria  in  pregnancy,  85 
AUantois,  48 
Amnion,  48,  53 

abnormalities  of,  91 
Amniotic  fluid,  source  of,  91 
Anatomical  inlet,  7 

land  marks  in  pelvis,  154 
Anomalous  presentations,  143 
Anterior  commissure,  35 

displacements  of  the  uterus,  81 
Antiseptic  methods  in  labor,  108 

17  25 


Area  germinativa,  47 

Areola,  43 

Armamentarium    of    the    physician  in 

labor,  IIS 
Artificial  abortion,  63 
Asphyxia  livida,  215 

neonatorum,  215 
treatment  of,  215 

pallida,  215 
Atresia  of  the  os,  147 


B 


Bag  of  waters,  105 

Ballottement,  loi 

Bandl  contraction  ring  of,  17 

Bartholin  glands  of,  34 

Battledore  placenta,  87 

Bed,  preparation  of,  for  labor,  109 

Bipolar  version,  185 

Bladder,  attention  to  after  labor,  206 

Blood,  fetal,  53 

supply  of  uterus,  19,  20 
Bowels,  attention  to  after  labor,  207 
Braxton  Hick's  bipolar  version,  185 

sign  of  pregnancy,  97 
Breasts,  43 

areola  of,  43 

changes  in,  during  pregnancy,  98 
structure  of,  43 
Breech  presentation,  134 
dangers  of,  135 
diagnosis,  135 
management  of,  136 
mechanism,  134 
premature  respiration  in,  135 
position  of,  123 
posterior  rotation  of  the  occiput 

in,  139 
various  methods  of  extraction  in, 
139 
Broad  ligament,  23 
Brow  presentation,  134 


252 


INDEX 


Bulbs  of  vagina,  33 

Byrds  method  of  resuscitation,  215 


Caput  succedaneum,  118 
Cardinal  points  of  Capuron,  9 

ligament  of  Kock's,  23 
Carus,  curve  of,  15 
Caruniculse  myrtiformes,  33 
Caul,  158 

Celio-hysterectomy,  197 
Celio-hysterotomy,  191 

indications  for,  197 
Cephalhematoma,  214 

causes,  214 

diagnosis,  215 

symptoms,  214 

treatment,  215 
Cephalic  version,  185 
Certain  signs  of  pregnancy,  98 
Cervix,  17 

changes  in  pregnancy,  94 

edema  of,  147 
treatment  of,  147 

immediate  repair  of,  I7S 

laceration  of,  175 

mucous  membranes  of,  22 

openings  of,  17 
Cesarean  section,  191 

definition,  191 

indication  for,  191 

instruments  for,  194 

technique,  191 

vaginal,  195 

indication  for,  195 
technique,  196 
Child,  congenital  defects  of,  213 

direction  for  nursing,  118 

first  attention  to  the,  113 
Chloasma,  79 
Chorio-epithelioma,  90 
Chorion,  formation  of,  55 

frondosum,  56 

Loeve,  55 
Circumference  of  fetal  head,  123 
Climacteric,  42 
Clitoris,  36 
Cloaca,  34 
Coccyx  the,  3 
Combined  or  bipolar  version,  186 

indication  for,  186 


Combined  or  bipolar  version,  technique, 

186 
Combined  version,  185 
Conception,  44 

Conjugate  diameters  of  pelvic  inlet,  9 
Conjunctivitis  of  the  new-born,  217 

causes,  217 

prognosis,  218 

symptoms,  218 

treatment,  218 
Constipation,  84,  85 

treatment  of,  84 
Contracted  pelvis,  149 
Contraction  ring  of  Bandl,  17,  166 
Cornual  pregnancy,  79 
Cranioclasm,  189 
Craniotpmy,  189 
Credo's  method,  106 
Criminal  abortion,  63 
Curve  of  Carus,  15 

D 

Death  of  fetus,  diagnosis  of  the,  88 
Decidua  ovulars,  50 

placental,  50 

reflexa,  50,  55 

serotina,  50 

uterine,  50 

vera,  50 
Development  of  external  sexual  organs, 

34 

Diameter  of  fetal  head,  120 
trunk,  123 
of  pelvic  inlet,  cavity  and  outlet,  9, 
10,  II 

Diarrhea,  84 

Diet  after  labor,  117 

Differential  diagnosis  between  threat- 
ened, inevitable,  incomplete 
and  complete  abortion,  65 

Directions  which  should  be  given  a 
woman  after  labor,  117 

Diseases  of  the  organs  of  generation,    80 

Distinguishing  marks  on  the  fetal  head, 
120 

Douglas'  cul-de-sac,  31 

Draeger's  pulmotor,  216 

Duties  of  a  physician  during  labor,  108 

Dystocia,     143 

ovular,  157 
placental,  172 


INDEX 


253 


E 


Earliest   period   of   intra-uterine  life   at 
which  the  sex  of  embryo  can  be 
recognized,  35 
Eclampsia,  167 
causes  of,  168 
clinical  history,  168 
definition,  167 
diagnosis,  169 
preventive  treatment,  170 
prodromic  symptoms,  168 
treatment  of  the  attack,  170 
Ectoderm,  47 
Ectopic  pregnancy,  72 
causes  of,  73 
diagnosis,  75 
classification  of,  73 
pathology,  73 
symptoms,  74 
termination  of,  77 
treatment,  77 
Eff  ect  of  maternal  conditions  on  labor, 

162 
Embryo,   coverings   of,  when   placental 
circulation  is  established,  50 
means  of  nourishment  of,  49 
Embryonic  abortion,  63 
Embryotomy,  189 
technique,  189 
Emphysema  of  the  neck,  175 
Endoderm,  47 
Endometrium,  21 
Epiblast,  47 
Episiotomy,  113 

External  measurements  of  pelvis,  154 
organs  of  generation,  34 

function  of,  43 
version,  185 
indication,  186 
technique,  186 
Extra  uterine  pregnancy,  72 
Extra  amniotic  sac,  158 
Extraction  of  the  after  coming  head  in 
Breech  labors,  various  methods, 
139 


F 


Face  presentation,  130 
causes  of,  130 


Face,  diagnosis,  131 
mechanism  of,  131 
position  of,  123 
treatment,  132 
Fallopian  tubes,  26 
structure  of,  26 
False  pelvis,  8 

Fatty  degeneration  of  the  placenta,  91 
Fecundation,  44 
Feeling  life,  loi 

Fetal  blood,  characteristics  of,  53 
circulation,  52 
head,  circumference  of,  123 
diameters  of,  121 
distinguishing  marks  on,  120 
fontanelles,  120 
planes  of,  122 
protuberances,  121 
sutures  of,  120 
heart  sounds,  99 

position  of  in  various  presenta- 
tions and  positions,  99 
movements,  100 
trunk,  diameter  of,  123 
Fetus,  diagnosis  of  the  death  of,  88 
papyraceous,  72 
size  of,  at  various  months,  56 
Fontanelles,  120 
Foot  and  head  presentation,  160 
Forceps,  obstetric,  176 

application  to  various    presenta- 
tions, 178  to  i8s  J 
Fourchette,  35 
Funic  souffle,  lor 
Funis,  52 

dimensions  of,  52 
knots  in,  52 
prolapse  of  the,  159 
diagnosis,  159 
treatment,  159 

G 

Galactorrhea,  213  j 

Generation,  external  organs  of,  34 

Genital  folds,  34 

ridges,  34 

tubercle,  34 
Glands   of   Montgomery    or    Morgagni, 

44 
Glands,  vulvovaginal,  34 
Graafian  follicles,  27 


254 


INDEX 


H 


Hare-lip,  214 

Hegar's  sign  of  pregnancy,  94 

Head  locking,  161 

Heart  sounds,  fetal,  99 

Hemorrhoids,  85 

Hemorrhage,  accidental,  67,  162 

postpartum,  163 

secondary,  165 

unavoidable,  163 
Hirsuties,  79 

Hour-glass  contraction,  172 
Hydatid  pregnancy,  88 

prognosis,  89 

symptoms  and  termination,  89 

treatment  of,  89 
Hydramnios,  92 

diagnosis,  92 

prognosis,  93 

symptoms,  92 

treatment,  93 
Hydrocephalus,  160 

management  of  labor,  complicated 
by,  160 
Hydrops  amnii,  158 
Hydrorrhoea,  gravidarum,  90 
Hymen  annularis,  32 

cribriform,  32 

fimbricatum,  32 

imperforate,  32 
Hypoblast,  47 


Icterus  neonatorum,  221 
Ilio-ischiatic  line,  9 

pectineal  line,  7 
Imperforate  anus,  214 

hymen,  32 
Impregnation,  44 
Incarnation,  44 
Incarceration,  83 

results,  83 

symptoms,  83 

treatment,  83 
Induction  of  labor,  200 
indication,  200 
technique,  200 
Infant,  preparation  for,  no 
Inlet,  anatomical,  7 

obstetric,  7 


Indigestion,  84 

Infundibulo  pelvic  ligaments,  24 

Intermittent  contractions  of  the  uterus 

in  pregnancy,  97 
Internal  pelvimetry,  155 
Internal  version,  185 
indication  for,  185 
prognosis,  174 
technique,  185 
Inversion  of  the  uterus,  173 
causes  of,  173 
diagnosis,  173 
prognosis,  174 
treatment  of,  174 
Involution,  200 

period  of,  200 
Ischio-pubiotomy,  199 


Jaundice  in  the  new-born,  221 
in  pregnancy,  84 

K 

Kidney  of  Oken,  16 
Kock's,  cardinal  ligament  of,  23 
KoUicker,  medullary  cords  of,  28 
Kristeller's  method,  145 
Kyphosis,  149 


Labia  majora,  35 

structure  of,  33 
minora,  36 

structure  of,  36 
Labor,  102 

anaesthetics  in,  no 
antiseptic  methods  in,  108 
attention  to  the  woman  after,  114 
articles  a  woman  should  prepare  for 

herself  and  child,  116 
changes    in    female    organism    just 

before,  102 
condition   of   health   after   normal, 

202 
definition,  102 
diet  after,  117 
difficult,  due  to  perineal  obstruction 

and  their  treatment,  148 
dilation  of  the  os  in,  104 


INDEX 


255 


Labor,  directions  to  give  a  nurse  after, 
117 

duties  of 'a  physician  during,  108 
during  second  stage  of,  iii 

effect  of  maternal  conditions  on,  162 

examinations  during,  109 

hemorrhages  in,  162 

induction  of,  200 

mechanism  of,  118  -- 

missed,  79 

normal  duration  of,  106 

objection  to  the  use  of  ergot  in,  145 
of  stimulants  in,  146 

pathology  of,  143 

premature,  63 

preparation  of  the  bed  for,  109 

position  of  the  womb  after,  114 

precipitate,  143 

stages  of,  103 

symptoms  of,  103 

syncope  in,  162 

twin,  161 
Laborde's  method  of  resuscitation,  217 
Lactation,  rules  to  be  observed  during, 

2G6 

Leucorrhoea,  80 
Ligaments  broad,  22 

infundibulo  pelvic,  24,  28 

ovarian,  28 

round,  24 

uterosacral,  24 

vesicouterine,  24 
Ligamentum  lata,  23 

transversali  colli  of  Mackenrodt,  23 
Linea  ilio-pectinea,  7 

terminale,  7 
Lineae  albicantes,  97 
Liquor  amnii,  54 

functions  of,  55 
Lithopaedion,  72 
L.  O.  A.  position,  diagnosis  of,  124 

and  presentation  mechanism  of,  125 
Lochia,  the,  202 
Lockjaw,  221 
Lymphatics  of  uterus,  20 

M 

Mackenrodt,  ligament  of,  23 
Maieutics,  i 

Malignant  deciduoma,  90 
treatment,  90 


Mastitis,  212 

symptoms,  212 

treatment,  212 

neonatorum,  220 
Mechanism  of  labor,  118 

forces  concerned  in,  119 
Meconium,  57 
Median  brown  line,  97 
Membrana  granulosa,  38 
Membranes,  too  thick,  158 
Menopause,  42 

symptoms  of,  42 
Menstruation,  40 

changes  in,  in  pregnancy,  97 

clinical  course  of,  40 

object  of,  41 

supplementary,  41 

synonyms  of,  41 

vicarious,  41 
Menstrual  blood,  peculiarities  of,  41 
Mesoblast,  48 
Mesovarian,  28 
Method  of  Prague,  139 
Milk,  composition  of  human,  205 

fever,  205 

leg,  211 
Midwifery,  i 
Miscarriage,  63 

Miscellaneous  complications,  171 
Missed  labor,  79 
Modification  of  bony  pelvis  by  soft  parts, 

15 

of    pelvic   diameter  by   soft    parts, 

15 
Mole  pregnancy,  89 
Momburg's  belt,  164 
Monsters,  twin,  162 
Mons  veneris,  35 
Montgomery   or    Morgagni,    glands    or 

tubercles  of,  43 
Mouth-to-mouth  insufflation,  217" 
Morning  sickness,  treatment  of,  60 
Muguet,  221 
Mullers  ducts,  16 
Multipara,  106 
Multiple  pregnancy,  58 

causes  of,  59 

clinical  course  of,  59 

frequency  of,  58 
Myxoma  fibrosum,  90 
Muscles  of  pelvis.  15 


256 


INDEX 


N 

Neck,  emphysema  of,  175 
Nephritis  in  pregnancy,  85 

in  treatment,  85 
Nerves  of  uterus,  20 
Newborn,  conjunctivitis  of  the,  217 

jaundice  in  the,  221 

septic  infection  of,  219 
treatment,  219 

tetanus  in  the,  221 
Nipples,  44 

sore,  213 

structure  of,  44 
Nubility,  42 
Nullipara,  106 
Nymphae,  36 


O 


Obliquity  of  pelvis,  15 
Obstetric  bag,  contents  of,  115 
constants,  222 

anatomy  and  physiology,  222 
abnormal  pelves,  247 
abortion,  227 

changes  in  position  which  uterus 
undergoes    during    pregnancy, 
226 
diameter  of  fetal  head,  243 
differential      diagnosis      between 
twin  pregnancy  and  polyhy- 
dramnios, 249 
between  pregnancy   and  other 
tumors,  232 
dystocia,  246 
ectopic  pregnancy,  229 
embryology,  224 
forceps,  249 

indication,  etc.  for  the  use   of, 
177 
inenstruation,  etc.,  227 
placenta  previa,  229 
pregnancy  complicated  by    uter- 
ine displacements,  230 
signs  and  diagnosis  of  pregnancy, 

231 
size  of    embryo    at  each    month, 

226 
synopsis,    of   the   mechanism    of 
labor  in  the  various  presenta- 
tions  and  positions,  243,   244, 
245,  246 


Obstetric  constants 

table   showing   differential  diag- 
nosis between  eclampsia  and 
other   convulsions,  248 
between  pregnancy  and  other 
conditions,    233.     234,    235, 
236,   237,  238 
table  showing   various  positions 
and    presentations,     238,    239, 
240,  241,  242 
table  of  differential   diagnosis   of 
various  forms  of   abortion,  228 
toxemia  of  pregnancy,  231 
forceps,  176 
inlet,  7 

operation.  176 
Obstetrics,  definition,  i 
Obturator  foramen,  6 

internus,  15 
Oligohydramnios,  93 
Ophthalmia  neonatorum,  218 
Organs  of  generation,  diseases  of  the,  80 

reproductive,  16 
Os,  dilatation  of,  in  labor,  104 

and  cervix,  rigidity  of  the,  in  labor, 

146 
uteri,   atresia   and  displacement  of 
the,  147 
treatment,  148 
Ossa  innominata,  3 
Ovarian  ligament,  28 
pregnancy,  73 
vessels,  28 
Ovaries,  accessory,  29 
attachments  of,  28 
functions  of,  37 
position  of,  27 
Ovary,  structure  of,  28 
Oviducts,  26 

function  of,  42 
Ovula  Nabothi,  22 
Ovulation,  37,  38 
Ovular  decidua,  50 

dystocia,  157 
Ovum,  changes  in,  after  impregnation , 
46 
coverings  of,  39 
segmentation  of,  47 
size  of,  50 

size  of  at  various  months,  56 
structure  of,  38 
Oxytocics,  145 


INDEX 


257 


Painless  contraction  of  the  uterus,  103 
Palpation,  100 
Parametrium,  23 
Parovarium,  29 
Pathology  of  pregnancy,  60 

of  labor,  143 
Pectineal  eminence,  9  *. 
Pelvic  cavity,  8 

depth  of,  10 
diameters  of,  157 
landmarks  of,  10 
diameter,  modification  of  by  soft 

parts,  IS 
floor,  36 
inlet,  7 

anatomical  landmarks  of,  8 
conjugate  diameters  of,  9 
oblique  diameters  of,  10 
transverse  diameter  of,  10 
isthmus,  7 
margin,  7 

outlet,  boundaries  of,  10 
diameters  of,  10,  157 
Pelvimetry,  external,  155 

internal,  155 
Pelvis,  anatomical  landmarks  of,  154 
axis  of,  14 
beams  of,  4 
bones  of  obstetrical,  3 
contracted,  149 
compressed,  149 
coxalgic,  153 
deformities,  of  mechanism  of  labor 

in,  153 
deformed,     degree    of    contraction 
compatable  with  delivery,  153 
diameters  of,  9 

distinguishing     characteristics     be- 
tween male  and  female,  6 
effect  of  deformities  of  the  inlet  on, 
153 
on  labor,  150 
external  measurements  of,  154 
false,  8 

boundaries  of,  8 
funnel-shaped,  149 
joints  of,  6 
justo  major,  149 
minor,  149 


Pelvis,  lining  of,  15 

method  of  examining,  154 

modification  of  the  bony,   by  soft 
parts,  IS 

muscles  of,  15 

narrowed  by  exostosis,  etc.,  150 

obliquely  contracted,  149 

obliquity  of,  is 

osteomalacic,  153 

planes  of,  11,  12 

rachitic  fiat,  149 

simple  flat,  149 

scoliotic,  150 

spondylolisthetic,  149 

true,  8 

boundaries  of,  8 

the,  3 
Perineal  body,  37 
Perineum,  36 

protection  of  in  labor,  112 

repair  of  laceration  of,  176 
Pernicious  vomiting  of  pregnancy,  61 
Phlegmasia  alba  dolens,  211 

treatment,  211 

symptoms,  211 
Physiology,  37 
Placenta,  abnormalities  of,  87 

adherent,  172 

battledore,  87 

delivery  of,  106 

development  of,  so 

dimensions  of,  S2 

fatty  degeneration  of  the,  91 

function  of,  51 

membranacea,  87 

premature  detachment  of,  67 

previa,  69 
causes  of,  69 
complications  of.  71 
danger  of,  70 
definition,  69 
treatment  of,  70 
varieties  of,  69 

retained  treatment  of,  66 

succenturia,  87 

syphilitic,  91 
Placental  apoplexy,  90 

decidua,  50 

dystocia,  172 
Podalic  version,  185 
Porro's  operation,  196 


258 


INDEX 


Porro's  operation,  197 
indications  for,  197 
technique,  197 
Position,  123 
Posterior  commissure,  35 

occipital    presentation,  130 
treatment,  130 
Post-partum  hemorrhage,  163 
causes,  163 
definition,  163 
symptoms  of,  163 
treatment,  163 
Prague,  method  of,  139 
Precipitate  labor,  143 
Pregnancy,  44 

Abderhalden's  test  for,  94 

abdominal,  73 

albuminuria  in,  85 

certain  signs  of,  98 

changes  in  menstruation  during,  97 

chorea  in,  86 

constipation  and  hemorrhoids  in,  85 

cornual,  79 

definition,  44 

duration  of,  88,  loi 

dyspnea  in,  85 

ectopic,  72 

extrauterine,  72 

table   showing    differential    diag- 
nosis of,  75.  76 
Hegar's  sign  of,  95 
hydatid,  88 

infectious  diseases  in,  86 
in  one  horn  of  a  bicornate  uterus,  73 
interstitial,  73 

intrauterine     with    lateral    flexion, 
differential  diagnosis,  76 
with  fibroid  tumor;  table  show- 
ing differential  diagnosis  of,  75 
jaundice  in,  84 
treatment,  85 
methods  for  calculating,  loi 
mole,  89 
multiple,  58 
nephritis  in,  85 
neuralgia  in,  86 
objective  signs  of,  94 
ovarian,  73 
pathology  of,  60 
pernicious  vomiting  in,  61 
signs  of,  93 

due  to  development  of  uterus,  94 


Pregnancy,  to   increased  vital  activity, 

94 

to  the  pressure  of  the  fetus,  99 
spurious,  96 
subjective  signs  of,  94 
synonyms,  44 
tubal,  73 

tuberculosis  in,  86 
tubo-uterine,  73 
tumors  which  may  be  confounded 

with.  95 
vomiting,  60 
Premature  detachment  of  the  placenta, 67 
causes  of,  67 
diagnosis  of,  68 
symptoms  of,  68 
treatment  of,  68 
labor,  63 
respiration,  135 
Presentation,  120 

anomalous,  143 
Primipara,  106 
Primitive  trace,  48 
Prolapse  of  the  pregnant  uterus,  84 
treatment  of,  84 
of  the  uterus,  81 
Protuberances,  121 
Pruritus  vulvse,  80 
Psoas  iliacus,  15 
Puberty,  42 
Pudenda,  34 
Puerperal  period,  200 

general  care  during,  203 
sapraemia,  207 
courses  of,  207 
treatment,  208 
septicemia,  207 
causes  of,  208 
pathology,  209 
symptoms,  208 
treatment,  209 
chronic,  209 
treatment,  210 
Pulmotor,  Draeger's,  216 
Pyosalpinx,    differential   diagnosis  from 
intra-   and    extrauterine    preg- 
nancy, 76 
Pyriformis,  15 


Q 


Quickening,  loi 


INDEX 


259 


R 


Relation  between  fetal  head  and  pelvic 

inlet,  156 
Reproductive  organs,  16 

development  of  internal,  16 
■  internal,  16 
Resuscitation  of  an  asphyxiated  child, 

215 
Retained  placenta,  66 
Retinaculum  of  Martin,  23 
Retrodisplacements  of  the  uterus,  82 
Rigidity  of  the  os  and  cervix,  146 

treatment  of,  147 
R.  O.  A.  position  and  presentation,  127 
R.  O.  P,  position  and  presentation,  127 

causes  of,  127 

diagnosis  of,  129 

mechanism  of,  128 
RosenmuUer,  organ  of,  29 
Round  ligaments,  24 
Rupture  of  the  uterus,  166 

causes  of,  166 

symptoms  of,  167 
of  threatened,  166 

treatment  of,  167 


Sacral  promontory,  7 

Sacro-sciatic  nocch,  6 

Sacrum,  the,  3 

Salivation,  79 

Schultze's  method  of  resuscitation,    217 

Secondary  hemorrhage,  165 

Septic  infection  in  the  newborn,  219 

Sexual  organs,  development  of  external, 

34 
Shoulder  presentation,  management  of, 
142 
modes  of  delivery  in,  142 
Signs  of  pregnancy,  93 
Smellie's  method  of  extraction,  139 
Smellie-Veit  method  of  extraction,  139 
Sore  nipples,  213 
Souffle,  funic,  loi 

utero  placental,  100 
Spermatozoon,  44 

agents  that  destroy,  45 
that  prolong  life  of,  45 
Spina  bifida,  214 


Spontaneous  abortion,  63 
Sprue,  221 

Spurious  pregnancy,  96 
Sub-involution,  201 

causes,  201 

symptoms,  201 

treatment,  201 
Superfecundation,  59 
Superfetation,  59 
Superimpregnation,  59 
Superinvolution,  201 
Supplementary  menstruation,  41 
Supports  of  uterus,  24 
Sutures,  120 

Sylvester's  method  of  resuscitation,   216 
Symphysiotomy,  197 

after-treatment,  199 

indications,  197 

prognosis,  199 

technique,  198 
Syncytial  tumors,  90 
Syphilitic  placenta,  91 


Tampon,  71 

method  of  applying,  71 
Tetanus  neonatorum,  221 
Therapeutic  abortion,  63 
Thrush,  221 
Tocology,  I 
Transfusion,  165 
Transverse  presentation,  position  of,  124 

or  shoulder  presentation,  141,  142 
True  pelvis,  8 
Tubal  pregnancy,  73 
Tubercles  or  glands  of  Montgomery,  43 
Tubo-uterine  pregnancy,  73 
Tumors  obstructing  delivery  and,  their 
treatment,  148 
which  may  be  confounded  with  the 
pregnant  uterus,  95 
Twin  labor,  161 

course  of,  161 
difficulties  in,  161 
fetal  appendages  in,  162 
monsters,  162 

U 

Umbilicus,  the,  219 
Umbilical  cord,  52 


26o 


INDEX 


Umbilical  cord,  ligation  and  dressing  of 
the,  113.  114 

hemorrhage,  219 

hernia,  219 

treatment,  219 
Umbilicus,  vegetation  of,  220 
Unavoidable  hemorrhage,  163 
Unipara,  106 
Urethra,  female,  36 
Uterine  decidua,  50 

development,  cause  of  anomalies  of, 
26 

inertia,  143 
causes  of,  144 
treatment  of;  144 

mucous   membranes,  distinguishing 
characteristics  of,  22 

thrombosis,  211 
Utero-sacral  ligaments,  24 

placental  vacuum,  173 
souffle,  100 
Uterus,  16 

anterior  displacements  of  the,  81 

bicornis,  26 

blood  supply  of,  19 

broad  ligaments  ot,  23 

cavity  of,  17 

cervix  or  neck  of,    17 

changes  in,  during  pregnancy,  57 

changes  in  pregnancy,  94 

cordiformis,  26 

cornua  of,  17 

double,  25 

duplex  J  26 

function  of,  42 

hour-glass  contraction  of,  172 

intermittent  contraction  of  the,  dur- 
ing pregnancy,  97 

inversion  of,  173 

ligaments  of,  22,  23,  24 

lymphatics  of,  20 

mucous  membrane  of,  21 

nerve  supply  of,  20 

painless  contractions  of  the,  103 

peritoneal  coverings  of,  23 

position  of,  24 

prolapse  of  the,  81 
pregnant,  84 

retrodisplacements  of  the,  82 
treatment  of,  82 

round  ligaments  of,  24 


Uterus,  rupture  of,  166 
semi-partitus,  25 
septus  bilocularis,  25 
shape  and  dimensions  of,  17 
structure  of,  17 
sub-involution  of,  201 
superinvolution  of,  201 
supports  of,  24 
unicornis,  25 


V 


Vagina,  29 

attachment  of,  29 

atresia  of,  148 

treatment,  148 

blood  supply  of.  30 

bulbs  of,  33 

function  of,  43 

lymphatics  of,  30 

mucous  membrane  of,  30 

structure  of,  30 

terminations  of,  31 
Vaginal  Cesarean  section,  195 
Varicose  veins,  79 
Vegetations  of  the  umbilicus,  220 

of  the  vulva,  80 
treatment  of,  So 
Velamentous  insertion  of  the  cord,  87 
Vernix  caseosa.  57 
Version,  185 

indication  for,  185 

various  kinds  of,  185 
Vertex,  presentation,  125 
Vesico-uterine  ligaments,  24 
Viable,  63 

Vicarious  menstruation,  41 
Vomiting  of  pregnancy,  60 
pernicious,  61 
symptoms,  62 
treatment  of,  63 
or  toxemic,  diagnosis,  62 
treatment  of,  61 
Vulva,  35 

vegetation  of  the,  80 
Vulvo-vaginal  glands,  34 

W 

Walcher's  position,  145 
Weid,  205 


INDEX  261 


Winekel's  disease,  220  •  X 

White  infarctions,  91 

Wolffian  bodies,  16  Xenomenia,  41 

Woman,  reproductive  organs  of,  2 

Womb,  changes   in  mucous  membrane  Z 

of,  following  fecundation,  50 
during  pregnancy,  57,  58  Zona  Pellucida,  39 


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